For children leaving the emergency department before being seen by a physician, counseling from nurses decreases return visits

To embrace and be present: The lived experiences of nurse-led consultations in Sweden from the perspective of pediatric nurses

PURPOSE

This study describes the lived experiences of nurse-led consultations in pediatric emergency departments from the perspective of pediatric nurses.

DESIGN AND METHODS

A descriptive qualitative study with a reflective lifeworld research approach was used to explore nurses' experiences of nurse-led consultations. The study was conducted through meaning-oriented individual interviews with ten pediatric nurses.

RESULTS

The results are grouped into four themes: (a) embracing the encounter and being touched by it; (b) having time to be present and committed; (c) having the ability and trusting in one's intuition; and (d) negotiating between families' wishes and the organization's guidelines.

CONCLUSIONS

Our study shows that nurse-led consultations conducted in separate nurse-led reception areas promote a positive experience of the consultations from the perspective of pediatric nurses. In a nurse-led consultation, a nurse's confidence in their ability to provide care is connected to time, broad skills and knowledge, and a supportive organization.

PRACTICE IMPLICATIONS

As the rising global population increases the demand for healthcare services, pediatric emergency departments must streamline their services to provide patient-safe, high-quality health care. Nurse-led consultations are an effective means of meeting these growing demands. This study contributes to an understanding of pediatric nurses' experiences at both the individual level and a more structured level, namely that families' wishes and an organization's guidelines do not always coincide.

Discharge communication practices in pediatric emergency care: a systematic review and narrative synthesis

BACKGROUND

The majority of children receiving care in the emergency department (ED) are discharged home, making discharge communication a key component of quality emergency care. Parents must have the knowledge and skills to effectively manage their child's ongoing care at home. Parental fatigue and stress, health literacy, and the fragmented nature of communication in the ED setting may contribute to suboptimal parent comprehension of discharge instructions and inappropriate ED return visits. The aim of this study was to examine how and why discharge communication works in a pediatric ED context and develop recommendations for practice, policy, and research.

METHODS

We systematically reviewed the published and gray literature. We searched electronic databases CINAHL, Medline, and Embase up to July 2017. Policies guiding discharge communication were also sought from pediatric emergency networks in Canada, USA, Australia, and the UK. Eligible studies included children less than 19 years of age with a focus on discharge communication in the ED as the primary objective. Included studies were appraised using relevant Joanna Briggs Institute (JBI) checklists. Textual summaries, content analysis, and conceptual mapping assisted with exploring relationships within and between data. We implemented an integrated knowledge translation approach to strengthen the relevancy of our research questions and assist with summarizing our findings.

RESULTS

A total of 5095 studies were identified in the initial search, with 75 articles included in the final review. Included studies focused on a range of illness presentations and employed a variety of strategies to deliver discharge instructions. Education was the most common intervention and the majority of studies targeted parent knowledge or behavior. Few interventions attempted to change healthcare provider knowledge or behavior. Assessing barriers to implementation, identifying relevant ED contextual factors, and understanding provider and patient attitudes and beliefs about discharge communication were identified as important factors for improving discharge communication practice.

CONCLUSION

Existing literature examining discharge communication in pediatric emergency care varies widely. A theory-based approach to intervention design is needed to improve our understanding regarding discharge communication practice. Strengthening discharge communication in a pediatric emergency context presents a significant opportunity for improving parent comprehension and health outcomes for children.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42014007106.

An Innovative Model to Predict Pediatric Emergency Department Return Visits

OBJECTIVES

Return visit (RV) to the emergency department (ED) is considered a benchmarking clinical indicator for health care quality. The purpose of this study was to develop a predictive model for early readmission risk in pediatric EDs comparing the performances of 2 learning machine algorithms.

METHODS

A retrospective study based on all children younger than 15 years spontaneously returning within 120 hours after discharge was conducted in an Italian university children's hospital between October 2012 and April 2013. Two predictive models, artificial neural network (ANN) and classification tree (CT), were used. Accuracy, specificity, and sensitivity were assessed.

RESULTS

A total of 28,341 patient records were evaluated. Among them, 626 patients returned to the ED within 120 hours after their initial visit. Comparing ANN and CT, our analysis has shown that CT is the best model to predict RVs. The CT model showed an overall accuracy of 81%, slightly lower than the one achieved by the ANN (91.3%), but CT outperformed ANN with regard to sensitivity (79.8% vs 6.9%, respectively). The specificity was similar for the 2 models (CT, 97% vs ANN, 98.3%). In addition, the time of arrival and discharge along with the priority code assigned in triage, age, and diagnosis play a pivotal role to identify patients at high risk of RVs.

CONCLUSIONS

These models provide a promising predictive tool for supporting the ED staff in preventing unnecessary RVs.

Leaving the emergency department without complete care: disparities in American Indian children

BACKGROUND

Children who leave the emergency department (ED) without complete evaluation or care (LWCET) have poorer outcomes in general. Previous studies have found that American Indian (AI) children have higher rates of LWCET than other racial or ethnic groups. Therefore, this study aims to examine LWCET in AI children by exploring differences by ED location and utilization patterns.

METHODS

This is a retrospective cohort study of five EDs in the upper Midwest between June 2011 and May 2012. We included all visits by children aged 0-17 who identified as African American (AA), AI or White. Logistic regression was used to determine differences in LWCET by race and ED location controlling for other possible confounding factors including sex, age, insurance type, triage level, distance from ED, timing of visit, and ED activity level.

RESULTS

LWCET occurred in 1.73% of 68,461 visits made by 47,228 children. The multivariate model revealed that AIs were more likely to LWCET compared to White children (Odds Ratio (OR) = 1.62, 95% Confidence Interval (CI) = 1.30-2.03). There was no significant difference in LWCET between AA and White children. Other factors significantly associated with LWCET included triage level, distance from the ED, timing of visit, and ED activity level.

CONCLUSION

Our results show that AI children have higher rates of LWCET compared to White children; this association is different from other racial minority groups. There are likely complex factors affecting LWCET in AI children throughout the upper Midwest, which necessitates further exploration.

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Objectif

L’objectif de cette étude rétrospective était d’identifier les facteurs associés aux décomptes quotidiens de départs avant prise en charge médicale (DAPCM) dans les deux salles d’urgence du Centre hospitalier universitaire de Sherbrooke, Fleurimont (HF) et Hôtel-Dieu (HD).

Méthode

Des données cliniques et démographiques anonymisées, ainsi que des données hospitalières, ont été extraites de la banque de données du Centre Informatisé de Recherche Évaluative en Services et Soins de Santé pour la période du 1er avril 2011 au 30 juin 2012. Les variables étant corrélées au nombre de DAPCM par jour par site lors des analyses univariées ont été retenues pour l’analyse de régression linéaire multivariée.

Résultats

Les analyses de régression multivariées démontrent que le nombre de DAPCM par jour diminue pour les deux sites lorsque la durée moyenne de séjour des patients non hospitalisés à l’urgence diminue (HF:b=1,17, p<0,001; HD:b=1,41, p<0,001) et lorsqu’un médecin dédié aux patients ambulatoires est présent (HF:b=-4,35, p<0,001; HD:b=-5,48, p<0,001). De plus, des facteurs reliés à l’achalandage des salles d’urgence et la raison primaire de consultation ont également eu un effet sur le nombre de DAPCM par jour.

Conclusion

Des efforts devraient être faits afin de diminuer la durée moyenne de séjour des patients non hospitalisés à l’urgence et d’assurer la présence d’un médecin dédié aux patients ambulatoires pour diminuer le nombre de DAPCM.

Unfavourable outcome for children leaving the emergency department without being seen by a physician

Objective:

To assess the prevalence of an unfavourable outcome among children leaving without being seen by a physician in the emergency department (ED).

Method:

This was a prospective cohort study conducted over a complete year in a pediatric tertiary care ED. A random sample of all children younger than 19 years of age who left without being seen by a physician was contacted by phone 4 to 6 days following the ED visit. The primary outcome was the occurrence of an unfavourable outcome prospectively defined using a Delphi method among 15 pediatric emergency physicians. An unfavourable outcome was defined as hospitalization, the need for an invasive procedure (intravenous or intramuscular medication, fracture reduction, bone casting, or surgical intervention), suicide attempt, or death in the 72 hours following leaving without being seen by a physician. As a secondary outcome, multiple potential predictors were evaluated. The first analysis evaluated the proportion of unfavourable outcomes among children who left without being seen by a physician. Then logistic regression identified predictors of unfavourable outcomes.

Results:

During the study period, 61,909 children presented to the ED, 7,592 (12%) left without being seen by a physician, and 1,579 were recruited. Thirty-eight (2.4%; 95% CI 1.7–3.2) patients fulfilled the criteria for an unfavourable outcome. On multiple logistic regression, chief complaints related to trauma and absence of nurse counseling had higher risks of unfavourable outcome.

Conclusions:

Approximately 2% of children who left without being seen by a physician at a tertiary care pediatric ED had an unfavourable outcome.

Pediatric emergency department management benefits from appropriate early redirection of nonurgent visits

AIMS

Overcrowding at pediatric emergency departments (EDs) may result in delayed clinical management and higher risks of medical error. This study was designed to prospectively evaluate what parents of sick children seek emergency care for and how these patients are being assessed and managed.

METHODS

Patients aged 0 to 17 years seeking ED care at an urban Swedish university hospital, from 8 AM to 9 PM on 25 consecutive days, were included. Clinical urgency and further level of medical care were determined by experienced nurses based on individual clinical signs and vital parameters. Information on presenting problem, medical priority, gender, age, waiting time, day of week, time of day, and further management was recorded.

RESULTS

Among 1057 included children, two thirds were assessed by physicians, whereas one third were referred directly by nurses for other ED (n = 54) or primary care (n = 114), or sent home with medical advice (n = 176), more often during evenings and weekends. Of primarily referred patients, 7.6% returned within 72 hours, and three of them were admitted. Young infants, patients with respiratory or neurological problems, and sicker patients with fever or infections were mainly assessed by physicians, within desired priority time.

DISCUSSION

More than one fourth of pediatric ED patients might rapidly, appropriately, and safely be referred for primary care or sent home by experienced pediatric nurses soon after arrival, thereby facilitating management of urgent and more appropriate patients. Evaluations by physicians were primarily required in young infants and for urgent medical conditions demanding qualified pediatric skills.

Impact of case exposures on physician behavior responses in childhood poisoning: quality and cost implications

OBJECTIVES

When measuring physicians' competencies, there is no consensus as to what would constitute an optimum exposure in unintentional pediatric poisoning. In the absence of universal protocols and poison centers' support, the behavior responses of the physicians can vary depending on their exposure to cases. We sought to determine if there was a correlation between the case exposure and physicians' behavior choices that could affect quality and cost of care.

METHODS

A cross-sectional study was conducted in 2010, and a self-reporting survey questionnaire was given to the physicians in the pediatric emergency departments and primary care centers in the city of Al Ain. The physicians' responses were plotted against (a) the number of cases the physicians have had managed in the preceding 12 months and (b) the number of years the physicians have had been in practice

RESULTS

One hundred seven physicians partook in the survey. We found that the physicians who had managed more than 2 cases of childhood poisoning in the preceding year chose significantly more positive behavior responses when compared with those who had managed 2 cases or less. There was no significant difference when the responses were measured against the physicians' number of years of practice.

CONCLUSIONS

Physicians' practice effectiveness may improve if they manage at least 3 cases of childhood poisoning in a year. Physicians training modules could be developed for those physicians who do not get the optimum exposure necessary in improving physicians' behaviors associated with effective quality and cost efficiency.