Pediatric Emergency Department Overcrowding: Electronic Medical Record for Identification of Frequent, Lower Acuity Visitors. Can We Effectively Identify Patients for Enhanced Resource Utilization?

Primary Care Enhanced Access Services and the Association With Nonurgent Pediatric Emergency Department Utilization and Child Opportunity Index

OBJECTIVES

This study aims to examine the association between primary care practice characteristics (enhanced access services) and practice-level rates of nonurgent emergency department (ED) visits using ED and practice-level data. Survey data suggest that enhanced access services within a child's primary care practice may be associated with reduced nonurgent ED visits.

METHODS

We performed a cross-sectional analysis of nonurgent ED visits to a tertiary pediatric hospital in Western Pennsylvania with nearly 85,000 annual ED visits. We obtained patient encounter data of all nonurgent pediatric ED (PED) visits between January 2018 and December 2019. We identified the primary care provider at the time of the study period. For each of the 42 included offices, we determined the number of unique children in the office with a nonurgent PED visit, allowing us to determine the percentage of children in the practice with such a visit during the study period. We then stratified the 42 offices into low, intermediate, and high tertiles of nonurgent PED use. Using Kruskal-Wallis tests, logistic regression, and Pearson χ 2 tests, we compared practice characteristics, enhanced access services, practice location Child Opportunity Index 2.0, and PED visit diagnoses across tertiles.

RESULTS

We examined 52,459 nonurgent PED encounters by 33,209 unique patients across 42 outpatient offices. Primary care practices in the lowest ED visit tertile were more likely to have 4 or more evenings with office hours (36% vs 14%, P = 0.04), 4 or more evenings of weekday extended hours (43% vs 14%, P = 0.05), and at least 1 day of any weekend hours (86% vs 29%, P = 0.01), compared with practices in other tertiles. High PED use tertile offices were also associated with lower Child Opportunity Index scores.

CONCLUSIONS

Primary care offices with higher nonurgent PED utilization had fewer enhanced access services and were located in neighborhood with fewer child-focused resources.

Community healthcare appointments as an alternative to emergency department assessment: an exploration of family acceptability and preferences

PURPOSE

Pediatric emergency departments are overcrowded, in part due to many non-emergent visits. We aimed to assess the proportion of parents interested in leaving the pediatric emergency department (ED) prior to physician assessment if they could be offered a scheduled community healthcare appointment. We explored differences in care children received in the ED stratified by interest in a community healthcare appointment and parents' reasons when they were not interested.

METHODS

We conducted a 14-item survey within the pediatric ED at a Canadian tertiary care teaching hospital to assess parents' interest if a program offered community healthcare appointments and we determined preferred appointment characteristics. All parents presenting with children triaged as CTAS 2-5 who met eligibility criteria were approached by a research assistant prior to physician assessment. Surveys were paired with the medical chart outlining the care received. Descriptive statistics and a regression model were used to describe characteristics of families and care received among those who were and were not interested in a community healthcare appointment.

RESULTS

In total, 403 surveys were completed. Overall, 236 participants (58.6%; 95% CI 53.8-63.4) were interested in a community healthcare appointment. In general, parents who were interested in a community healthcare appointment were younger and presented with younger children compared to those who were not interested. Among those interested, there was a preference to have the appointment with a pediatrician or family physician, timely access to an appointment, and appointments scheduled outside of regular business hours.

CONCLUSION

Our study provides evidence that there is interest in an alternative care access model positioned to reduce pediatric ED congestion. We found that parents would be interested in leaving the pediatric ED in favor of a community healthcare appointment, provided it was with a physician and available in a timely manner.

Redirecting Nonurgent Patients From the Pediatric Emergency Department to Their Pediatrician Office for a Same-Day Visit-A Quality Improvement Initiative

OBJECTIVES

Providing high-quality care in the appropriate setting to optimize value is a worthy goal of an efficient health system. Consequences of managing nonurgent complaints in the emergency department (ED) have been described including inefficiency, loss of the primary care-patient relationship, and delayed care for other ED patients. The purpose of this initiative was to redirect nonurgent patients arriving in the ED to their primary care office for a same-day visit, and the SMART AIM was to increase redirected patients from 0% of those eligible to 30% in a 12-month period.

METHODS

The setting was a pediatric ED (PED) and primary care office of a tertiary care pediatric medical system. The initiative utilized the electronic health record to identify and mediate the redirection of patients to the patient's primary care office after ED triage. The primary measurement was the percentage of eligible patients redirected. Additional measures included health benefits during the primary care visit (vaccines, well-visits) and a balancing measure of patients returned to the PED.

RESULTS

The SMART AIM of >30% redirection was achieved and sustained with a final redirection rate of 46%. In total, 216 of 518 eligible patients were redirected, with zero untoward outcomes. The encounter time for redirected patients was similar for those who remained in the PED, and additional health benefits were appreciated for redirected patients.

CONCLUSIONS

This initiative redirected nonurgent patients efficiently from a PED setting to their primary care office. The process is beneficial to patients and families and supports the patient-centered medical home. The balancing measure of no harm done to patients who accepted redirect reinforced the reliability of PED triage. The benefits achieved through the project highlight the value of the primary care-patient relationship and the continued need to improve access for patients and families.

Practice Pattern Variation in Test Ordering for Low-Acuity Pediatric Emergency Department Patients

OBJECTIVES

Rising costs in healthcare have focused attention on interventions to optimize efficiency of patient care, including decreasing unnecessary diagnostic testing. The primary objective of this study was to determine the variability of laboratory and radiology testing among licensed independent providers (LIPs) with different training backgrounds treating low-acuity patients in a pediatric emergency department (PED).

METHODS

We performed a retrospective review of the electronic health records of all encounters with patients 21 years or younger, triaged as low-acuity, visiting 2 urban, academic PEDs from January 2012 to December 2013. We calculated frequency of orders for specific tests, including complete blood counts, aerobic blood cultures, urine cultures, and chest radiographs. Bivariable analyses were used to measure associations of test ordering between these LIP dyad groups: physician versus nurse practitioner (NP); physicians with pediatric emergency medicine fellowship training (PEM) versus physicians without PEM training and physicians with at least 5 years since residency graduation versus less than 5 years. We used multivariable logistic regression to adjust for potential confounders, including ED location, trainee co-management, and patient characteristics. We also performed sensitivity analyses by location.

RESULTS

There were 148,570 total encounters treated by 12 NPs and 144 physicians, of whom 60 were PEM physicians. Seventy-three physicians had 5 or more years of experience. Testing rates per patient encounter ranged from 0% to 40% for individual providers. In bivariable analyses, testing was more likely when the LIP was a physician (odds ratio [OR] = 1.2, 95% confidence interval = 1.1-1.2) or PEM trained (OR = 1.3, 1.2-1.3). In multivariable analyses, testing was more likely for encounters with PEM providers (adjusted OR [AdjOR] = 1.2, 1.1-1.3). A sensitivity analysis on a subset of encounters seen exclusively at our PED-based urgent care revealed that testing was also more likely for encounters seen by PEM physicians (AdjOR = 1.5, 1.4-1.7) and with NPs (AdjOR = 1.2, 1.1-1.4) compared with physicians.

CONCLUSIONS

Our study identified substantial variation in test ordering patterns for LIPs treating low-acuity patients. There were significant differences in ordering practices between providers from different training backgrounds, most significantly when comparing PEM with non-PEM providers. Further research should examine interventions to standardize practice across disciplines.

Reduction in pediatric gastroenterology ED visits can be sustained through physician accountability and financial incentives

OBJECTIVE

There have been various interventions to reduce ED utilization. Little is known about the sustainability of outcomes of interventions to reduce ED overcrowding. We sought to investigate whether the outcomes from one of successful interventions to reduce ED utilization, specialist physician level reporting were sustained over time and how this practice change was sustained over time.

METHOD

This study is a longitudinal analysis of the pre and post intervention ED utilization data collected on ED pediatric patients who were followed by pediatric gastroenterologists in an urban, academic hospital. The primary outcome was the mean rate of ED visits per 1000 office visits from January, 2013 to June, 2017 using a u control chart with three sigma limits.

RESULTS

There were continuous leadership's support, physicians' engagement and communications among different members involved in the intervention. The rate of gastrointestinal (GI)-related ED visits after an intervention decreased by 54% from 4.89 to 2.23 during all hours and by 59% from 2.19 to 0.91 during office hours.

DISCUSSION

Physician-level reporting reduced ED utilization over a four year period. The outcomes could be sustained over time with sustained leadership and physicians' engagement.

Non-urgent paediatric emergency department presentation: A systematic review

There has been an increase in the use of the emergency department (ED) for non-urgent presentations. The aim of this systematic review was to identify the proportion, criteria and predictors of non-urgent ED presentations in paediatric populations. A search of multiple databases was conducted for articles published from inception of the databases to 20 August 2018, which reported the proportion, criteria and predictors of non-urgent ED presentation in paediatric populations. Thirty-one articles met the inclusion criteria. The mean proportion of non-urgent paediatric ED presentations was 41.06 ± 15.16%. There appears to be a weak association between predisposing, enabling and needs factors and non-urgent ED use in paediatric populations. The findings of this review suggest that non-urgent ED use in paediatric populations is high. However, non-urgent ED use and the reasons for the visits in paediatric populations remain understudied.

Why Are Newborns Brought to the Emergency Department?

OBJECTIVES

Neonatal period is a peculiar life stage. This study aimed to characterize newborns' visits to the emergency department (ED) of a secondary care hospital.

METHODS

Retrospective analysis of infants up to 28 days, who resorted to the ED between January and December of 2014, was performed. The data included newborn and maternal demographic characteristics and characterization of visits in the ED.

RESULTS

From 378 newborns' visits in the ED, 77 were excluded because the visits did not meet the inclusion criteria. From the remaining 301 visits, corresponding to 266 newborns, 56 newborns were referred to hospital care by another doctor, and 34 returned to ED in the neonatal period. The majority of newborns were full term (94%), born by vaginal delivery (55.1%), and had an appropriate birth weight for gestational age (94%). The main reasons for ED visits were gastrointestinal symptoms (33.8%), mucocutaneous lesions (21.4%), and jaundice (16.2%). Half (53%) of the newborns' visits were considered nonurgent. Emergency department visits for reasons justifying medical evaluation were higher in those referred by another doctor (P < 0.001). The rate of hospitalization or guidance for consultation was higher in newborns referred by another doctor (P = 0.017), in those whose color attributed by Manchester Triage System was yellow or orange (P = 0.029) and in newborns older than 7 days (P = 0.035).

CONCLUSIONS

The majority of ED visits is owing to insufficient caretaker knowledge or benign symptoms without necessity of immediate medical evaluation. These results emphasize the need for parents' education by health professionals.

Predicting Low-Resource-Intensity Emergency Department Visits in Children

OBJECTIVES

Interventions to reduce frequent emergency department (ED) use in children are often limited by the inability to predict future risk. We sought to develop a population-based model for predicting Medicaid-insured children at risk for high frequency (HF) of low-resource-intensity (LRI) ED visits.

METHODS

We conducted a retrospective cohort analysis of Medicaid-insured children (aged 1-18 years) included in the MarketScan Medicaid database with ≥1 ED visit in 2013. LRI visits were defined as ED encounters with no laboratory testing, imaging, procedures, or hospitalization; and HF as ≥3 LRI ED visits within 365 days of the initial encounter. A generalized linear regression model was derived and validated using a split-sample approach. Validity testing was conducted examining model performance using 3 alternative definitions of LRI.

RESULTS

Among 743,016 children with ≥1 ED visit in 2013, 5% experienced high-frequency LRI ED use, accounting for 21% of all LRI visits. Prior LRI ED use (2 visits: adjusted odds ratio = 3.5; 95% confidence interval, 3.3, 3.7; and ≥3 visits: adjusted odds ratio = 7.7; 95% confidence interval, 7.3, 8.1) and presence of ≥3 chronic conditions (adjusted odds ratio = 1.7; 95% confidence interval, 1.6, 1.8) were strongly associated with future HF-LRI ED use. A model incorporating patient characteristics and prior ED use predicted future HF-LRI ED utilization with an area under the curve of 0.74.

CONCLUSIONS

Demographic characteristics and patterns of prior ED use can predict future risk of HF-LRI ED use in the following year. Interventions for reducing low-value ED use in these high-risk children should be considered.

Emergency department use by paediatric patients in Lombardy Region, Italy: a population study

OBJECTIVES

To estimate the rate of paediatric attendance at emergency departments (EDs) in the Lombardy Region, Italy, and to determine the factors contributing to different patterns of use.

METHODS

By analysing healthcare administrative databases, ED attendance by 1.6 million youths <18 years old during 2012 in the Lombardy Region was assessed. The pattern of use was categorised based on the number of ED visits and level of emergency, defined by triage code and outcome of the visit. Logistic regression analyses were performed to identify the characteristics of access for non-urgent reasons and those of patients with frequent non-urgent access (≥4 accesses for non-urgent reasons only). A case-control study was carried out to compare healthcare resource use by children 1-5 years old who were 'frequent non-urgent users' with that of randomly selected controls, matched by age, gender, nationality and primary care physician.

RESULTS

During 2012, 440 284 (27%) of children and adolescents had at least one ED attendance, with trauma (26%) and respiratory tract infections (22%) as the most frequent diagnoses. In all, 533 037 (79%) accesses were for non-urgent reasons, and 12 533 (3% of the ED users) were frequent non-urgent users. Male gender (OR 1.12; 95% CI 1.08 to 1.17), preschool age (OR 3.14; 95% CI 2.98 to 3.31) and place of residence (OR 1.74; 95% CI 1.70 to 1.99) were associated with a higher risk of being a frequent non-urgent user. Moreover, a greater healthcare consumption was observed in this group.

CONCLUSIONS

One out of four children and adolescents attended the ED at least once per year, 3% of whom were frequent non-urgent users, with a high overall healthcare resource consumption.

[The Spanish triage system in the evaluation of neonates in paediatric emergency departments]

The triage system in the emergency department classifies patients according to priority levels of care. Neonates are a vulnerable population and require rapid assessment.

OBJECTIVE

To correlate the priority levels in newborns seen in the paediatric emergency department with admissions, resource consumption, and service times.

PATIENTS AND METHOD

Observational study, using the Andorran triage model (MAT-SET) with ePATV4 software database, in paediatric emergencies. Neonates were classified into 3 levels of care established for them as level I resuscitation, level II emergency, and level iii urgent. The correlation between levels of priority and admission and resource consumption were analysed, as well as the time spent on medical care and stay in the emergency department.

RESULTS

The study included 1103 infants. The highest priority level was positively correlated with hospital admission (r = 0.66, P<.005) and resource consumption (r = 0.59, P < .005). The medical care times were 126 ± 203, 119 ± 51, and 33 ± 81 min for levels i, ii, and iii, respectively and the stay in emergency department was 150 ± 203, 131 ± 80, and 55 ± 86 min, respectively for these levels (P < .05).

CONCLUSION

The higher level of priority in the care of neonates in the paediatric emergency department was positively correlated with increased need for hospital admission and resource consumption. They also required a longer time for medical care and stay in the emergency department.

Predicting Subsequent High-Frequency, Low-Acuity Utilization of the Pediatric Emergency Department

OBJECTIVE

To derive and test a predictive model for high-frequency (4 or more visits per year), low-acuity (emergency severity index 4 or 5) utilization of the pediatric emergency department.

METHODS

The study sample used 3 years of data (2012-2014) from a single tertiary-care children's hospital for patients <21 years of age. Utilization in 2013 defined the index visit; prior utilization was drawn from 2012; and 2014 was used for outcome measurement. Candidate predictor variables were those that would be available at the time of triage. Data were split into derivation and test sets randomly; variables with a significant univariate association in the derivation set were included for multivariable modeling. The final model from the derivation set was then tested in the validation set, with calculation of a receiver operating characteristic curve.

RESULTS

There were 90,972 visits in 2013, of which 61,430 were first (index) visits. A total of 590 (1%) had 4 or more triage level 4 or 5 visits in the following year (2014). The final model included site of primary care, age, acuity, previous utilization, race, and insurance, and had an area under the receiver operating characteristic curve of 0.84.

CONCLUSIONS

Data available to the emergency department provider at the time of initial visit triage can predict utilization for low-acuity complaints in the subsequent year. Future work should focus on validation and refinement of the model in additional settings, and electronic calculation of risk status for targeted intervention to improve appropriate utilization of health care services.

Emergency Department Utilization Report to Decrease Visits by Pediatric Gastroenterology Patients

BACKGROUND AND OBJECTIVES

Emergency department (ED) utilization is a major driver of health care costs. Specialist physicians have an important role in addressing ED utilization, especially at highly specialized, academic medical centers. We sought to investigate whether reporting of ED utilization to specialist physicians can decrease ED visits.

METHODS

This study analyzed an intervention to reduce ED utilization among ED patients who were followed by pediatric gastroenterologists. In May 2013, each pediatric gastroenterologist began receiving reports with rates of ED use by their patients. The reports generated discussion that resulted in a cultural and process change in which patients with urgent gastrointestinal (GI)-related complaints were preferentially seen in the office. Using control charts, we examined GI-related and all-diagnoses ED use over a 2-year period.

RESULTS

The rate of GI-related ED visits decreased by 60% after the intervention, from 4.89 to 1.95 per 1000 office visits (P < .001). Similarly, rates of GI-related ED visits during office hours decreased by 59% from 2.19 to 0.89 per 1000 (P < .001). Rates of all-diagnoses ED visits did not change.

CONCLUSIONS

Physician-level reporting of ED utilization to pediatric gastroenterologists was associated with physician engagement and a cultural and process change to preferentially treat patients with urgent issues in the office.

Integrating care for frequent users of emergency departments: implementation evaluation of a brief multi-organizational intensive case management intervention

Background

Addressing the needs of frequent users of emergency departments (EDs) is a health system priority in many jurisdictions. This study describes stakeholder perspectives on the implementation of a multi-organizational brief intervention designed to support integration and continuity of care for frequent ED users with mental health and addictions problems, focusing on perceived barriers and facilitators to early implementation in a large urban centre.

Methods

Coordinating Access to Care from Hospital Emergency Departments (CATCH-ED) is a brief case management intervention bridging hospital, primary and community care for frequent ED users experiencing mental illness and addictions. To examine barriers and facilitators to early implementation of this multi-organizational intervention, between July and October 2012, 47 stakeholders, including direct service providers, managers and administrators participated in 32 semi-structured qualitative interviews and one focus group exploring their experience with the intervention and factors that helped or hindered successful early implementation. Qualitative data were analyzed using thematic analysis.

Results

Stakeholders valued the intervention and its potential to support continuity of care for this population. Service delivery system factors, including organizational capacity and a history of collaborative relationships across the healthcare continuum, and support system factors, such as training and supervision, emerged as key facilitators of program implementation. Operational challenges included early low program referral rates, management of a multi-organizational initiative, variable adherence to the model among participating organizations, and scant access to specialty psychiatric resources. Factors contributing to these challenges included lack of dedicated staff in the ED and limited local system capacity to support this population, and insufficient training and technical assistance available to participating organizations.

Conclusions

A multi-organizational brief intervention is an acceptable model to support integration of hospital, primary and community care for frequent ED users. The study highlights the importance of early implementation evaluation to identify potential solutions to implementation barriers that may be applicable to many jurisdictions.

Forecasting the effect of physician assistants in a pediatric ED

BACKGROUND

Most pediatric ED visits are for nonemergent problems. Physician assistants are well trained to manage these patients; however, their effect on patient flow in a pediatric ED is unknown.

OBJECTIVES

To compare the effect on key pediatric ED efficiency indicators of extending physician coverage versus adding PAs with equivalent incremental costs.

METHODS

We used discrete event simulation modeling to compare the effect of additional physician coverage versus adding PAs on wait time, length of stay (LOS), and patients leaving without being seen.

RESULTS

Simulation of extended physician coverage reduced wait times, LOS, and rates of leaving without being seen across acuity levels. Adding PAs reduced wait times and LOS for high-acuity visits, and slightly increased the LOS for low-acuity visits.

CONCLUSIONS

With restricted autonomy, PAs mainly benefitted the high-acuity patients. Increasing the level of PA autonomy was critical in broadening the effect of PAs to all acuity levels.

Differences in Presentation and Management of Pediatric Facial Lacerations by Type of Health Insurance

Introduction

Limited data are available regarding differences in presentation and management of pediatric emergency department (PED) patients based on insurance status. The objective of the study was to assess the difference in management of pediatric facial lacerations based on medical insurance status.

Methods

We conducted a retrospective cohort study with universal sampling of patients with facial lacerations who were treated in an urban PED (45K visits/year) over a one-year period. Demographic features and injury characteristics for patients with commercial (private) insurance and those with Medicaid or Medicare (public) insurance were compared.

Results

Of 1235 children included in the study, 667 (54%) had private insurance and 485 (39%) had public insurance. The two groups did not differ in age or gender, arrival by ambulance, location of injury occurrence, mechanism of injury, part of face involved, length or depth of laceration, use of local anesthetic, or method of repair but differed in acuity assigned at triage. Patients with public insurance were found less likely to have subspecialty consultation in bivariable (OR=0.41, 95% CI [0.24–0.68]) and multivariable logistic regression analyses (OR=0.45, 95% CI [0.25–0.78]). Patients with public insurance received procedural sedation significantly less often than those with private insurance (OR=0.48, 95% CI [0.29–0.76]). This difference was not substantiated in multivariable models (OR=0.74, 95% CI [0.40–1.31]).

Conclusion

Patients with public insurance received less subspecialty consultation compared to privately insured patients despite a similarity in the presentation and characteristics of their facial lacerations. The reasons for these disparities require further investigation.

Travel distances, socioeconomic characteristics, and health disparities in nonurgent and frequent use of Hospital Emergency Departments in South Carolina: a population-based observational study

BACKGROUND

Nonurgent use of hospital emergency departments (ED) is a controversial topic. It is thought to increase healthcare costs and reduce quality, but is also considered a symptom of unequal access to health care. In this article, we investigate whether convenience (as proxied by travel distances to the hospital ED and to the closest federally qualified health center) is associated with nonurgent ED use, and whether evidence of health disparities exist in the way vulnerable populations use the hospital ED for medical care in South Carolina.

METHODS

Our data includes 6,592,501 ED visits in South Carolina between 2005 and 2010 from the South Carolina Budget Control Board and Office of Research and Statistics. All ED visits by South Carolina residents with unmasked variables and nonmissing urgency measures, or approximately 76% of all ED visits, are used in the analysis. We perform multivariable linear regressions to estimate correlations between (1) travel distances and observable sociodemographic characteristics and (2) measures of nonurgent ED use or frequent nonurgent ED use, as defined by the New York University ED Algorithm.

RESULTS

Patients with commercial private insurance, self-pay patients, and patients with other payment sources have lower measures of nonurgent ED use the further away the ED facility is from the patients' home address. Vulnerable populations, particularly African American and Medicaid patients, have higher measures of nonurgent ED scores, and are more frequent users of the ED for both nonurgent and urgent reasons in South Carolina. At the same time, African Americans visit the hospital ED for medical conditions with higher primary care-preventable scores.

CONCLUSIONS

Contrary to popular belief, convenient access (in terms of travel distances) to hospital ED is correlated with less-urgent ED use among privately insured patients and self-pay patients in South Carolina, but not publicly insured patients. Unequal access to primary care appears to exist, as suggested by African American patients' use of the hospital ED for primary care-treatable conditions while experiencing more frequent and more severe primary care-preventable conditions.

Frequent pediatric emergency department use in infancy and early childhood

OBJECTIVE

To define the threshold and population factors associated with pediatric emergency department (PED) use above the norm during the first 36 months of life.

METHODS

We conducted a cross-sectional study of children born between 2003 and 2006, treated in a single PED within the first 36 months of life. Exclusion criteria included out-of-county residence or history of abuse or neglect. The primary outcome, frequent PED use, was defined by the 90th percentile for PED visits per patient. Multivariate analysis was used to identify factors associated with frequent PED use.

RESULTS

A total of 41,912 visits occurred for 16,664 patients during the study. Pediatric ED use skewed heavily toward less than 2 visits per patient (median, 2; range, 1-39; interquartile range, 2). The threshold for frequent PED use was 5 or more visits per patient and occurred for 14% (95% confidence interval [95% CI], 13%-15%) of patients. Most visits were coded with low acuity International Classifications of Diseases, 9th Revision, Clinical Modification codes. The following factors were strongly associated with frequent PED use: lack of primary care physician (odds ratio [OR], 6.03; 95% CI, 5.39%-6.80%; P < 0.0001), non private insurance (OR, 3.64; 95% CI, 2.99%-4.46%; P<0.0001), and history of inpatient admission (OR, 3.09; 95% CI, 1.66%-2.24%; P < 0.0001). Leaving without being seen, black race, Hispanic ethnicity, and residence in a poverty-associated zip code were also significantly associated, but less strongly predictive of, frequent PED use.

CONCLUSIONS

The threshold for frequent PED use was more than 5 visits per patient within the first 36 months of life. Further study is needed to better define this population and develop targeted interventions to ensure care provision occurs in the ideal setting.

Reconnecting patients with their primary care provider: an intervention for reducing nonurgent pediatric emergency department visits

OBJECTIVE

Intervention to reduce nonurgent pediatric emergency department (PED) visits over a 12-month follow-up.

METHODS

Prospective, randomized, controlled trial enrolled children seen in the PED for nonurgent concerns. Intervention subjects received a structured session/handout specific to their primary care provider (PCP), which outlined ways to obtain medical advice. Visitation to the PED and PCP were followed over 12 months.

RESULTS

A total of 164 patients were assigned to the intervention and 168 patients to the control. At 12-month follow-up, the intervention group had a lower rate of nonurgent PED utilization compared with the control group (70 [43%] patients in the intervention compared with 91 [54%] in the control; P = .047). At 12 months, there was an increase in the rate of sick visits to PCP in the intervention group when compared with the control (P = .036).

CONCLUSIONS

Intervention designed in cooperation with pediatricians was able to decrease nonurgent PED utilization and redirect patients to their PCP for future sick visits over a 12-month period.

Characteristics of paediatric frequent presenters to an Australian emergency medicine network

AIM

The study aims to describe the characteristics of paediatric emergency department (ED) patients defined as frequent presenters (FP) presenting to an Australian ED health service and compare these with a cohort of non-frequent presenters (NFP).

METHOD

A retrospective chart review utilising an electronic emergency medicine patient medical record database was performed on paediatric patients (18 years or younger) presenting to Monash Health EDs from March 2009 to March 2010. NFPs were defined as patients presenting five or less times and FPs as presenting eight or more times in the study period. Characteristics of both groups were described and compared.

RESULTS

During the 12-month study period, there were 130 paediatric FP patients with 839 admissions and 34,262 paediatric NFP patients with 46,043 admissions. FPs to the ED were more likely to be female, utilise the ambulance service to arrive at the hospital and more likely to be admitted to hospital. In particular, FPs were more likely to require admission for a mental health-related problem. They were also more likely to have a discharge diagnosis related to oncology, neurology, respiratory, endocrinology and psychiatric complaints, compared with NFP who were more likely to present with a diagnosis related to injury or trauma.

CONCLUSIONS

Paediatric FPs are a vulnerable population with complex multidisciplinary care needs. A holistic approach towards their needs is essential to understanding the reasons for their higher frequency of attendance. By considering all the elements of the child's well-being, the child and family need support to assist in integration with other non-ED service providers. By focusing on wellness and self-management, there is a potential to reduce the reliance on acute emergency care for ongoing chronic health problems.

How well do General EMS 911 dispatch protocols predict ED resource utilization for pediatric patients?

INTRODUCTION

The use of Emergency Medical Services (EMS) for low-acuity pediatric problems is well documented. Attempts have been made to curb potentially unnecessary transports, including using EMS dispatch protocols, shown to predict acuity and needs of adults. However, there are limited data about this in children. The primary objective of this study is to determine the pediatric emergency department (PED) resource utilization (surrogate of acuity level) for pediatric patients categorized as "low-acuity" by initial EMS protocols.

METHODS

Records of all pediatric patients classified as "low acuity" and transported to a PED in winter and summer of 2010 were reviewed. Details of the PED visit were recorded. Patients were categorized and compared based on chief complaint group. Resource utilization was defined as requiring any prescription medications, labs, procedures, consults, admission or transfer. "Under-triage" was defined as a "low-acuity" EMS transport subsequently requiring emergent interventions.

RESULTS

Of the 876 eligible cases, 801 were included; 392/801 had no resource utilization while 409 of 801 had resource utilization. Most (737/801) were discharged to home; however, 64/801 were admitted, including 1 of 801 requiring emergent intervention (under-triage rate 0.12%). Gastroenterology and trauma groups had a significant increase in resource utilization, while infectious disease and ear-nose-throat groups had decreased resource utilization.

DISCUSSION

While this EMS system did not well predict overall resource utilization, it safely identified most low-acuity patients, with a low under-triage rate. This study identifies subgroups of patients that could be managed without emergent transport and can be used to further refine current protocols or establish secondary triage systems.

A profile of nonurgent emergency department use in an urban pediatric hospital

OBJECTIVES

This study was designed to develop a descriptive profile of parents and caregivers who bring their children to the emergency department (ED) for nonurgent issues and to explore the reasons for presenting to an urban hospital pediatric ED for nonurgent conditions. Such work is necessary to develop effective interventions.

METHODS

A total of 106 parents/caregivers whose child was triaged with a nonemergent/urgent condition completed a 15- to 20-minute computerized survey (English and Spanish) in an urban pediatric ED.

RESULTS

Most respondents described themselves as Latino (76%) and foreign born (62%). About one half (49%) reported having an annual income of less than $20,000, and 43% of respondents did not have health insurance for themselves. Almost all (95%) of the index children had a primary care physician and health insurance. Despite being triaged as nonurgent, more than one half (63%) described their child's condition as "very" or "extremely" urgent. About one half of the respondents reported not receiving basic information on childhood illnesses from their child's physician. Reasons for nonurgent visits seemed to revolve around issues of convenience and perception of quality of care.

CONCLUSIONS

Interventions should focus on health literacy and ensure that parents are provided relevant and accurate education on pediatric illnesses and common safety concerns; by increasing parental education on pediatric health, parents may be better able to assess acuity of their child's health issues.

Emergency department care of seizure patients: demographic trends in southern Arizona

The aim of this study was to describe the epidemiology of epilepsy and characteristics of patients with seizures who presented at the Yuma Regional Medical Center Emergency Department (YRMC ED) from 2005 to 2008. A seizure diagnosis was present in 2.7% of the patients, and accounted for 1.7% of all ED visits. Visits by patients identified as having epilepsy accounted for 0.3% of all ED visits. Patients with seizures were 2.8 times more likely to have used the ED for 2 or more years of the study period compared with control patients. Patients with at least one ED visit because of seizures were more likely to have multiyear visits, 43.6% visiting the ED within 2 or more years. Patients with epilepsy and seizures were significantly younger than the no-seizure control group. Patients who had ever been admitted to the ED for seizures or epilepsy had higher ED utilization even if the subsequent admissions were not seizure related.