Variation in resource utilization across a national sample of pediatric emergency departments

Variation and Drivers of Costs for Emergency Department Visits Among Children in 8 States

OBJECTIVE

To describe variation in costs for emergency department (ED) visits among children and to assess hospital and regional factors associated with costs.

METHODS

Cross-sectional study of all ED encounters among children under 18 years in 8 states from 2014 to 2018. The primary outcome was each hospital's mean inflation-adjusted ED costs. We evaluated variability in costs between hospitals and determined factors associated with costs using hierarchical linear models at the state, region, and hospital levels. Models adjusted for pediatric case mix, regional wages, Medicaid share, trauma status, critical access status, ownership, and market competitiveness.

RESULTS

We analyzed 22.9 million ED encounters across 713 hospitals. The median ED-level cost was $269 (range 99-1863). There was a 5.1-fold difference in median ED-level costs between the lowest- and highest-cost regions (range 119-605). ED-level costs were associated with case mix index (+38% per 10% increase, 95% confidence interval [CI] 30 to 47); wages [+7% per 10% increase, 95% CI 5 to 9]); critical access (adjusted costs, +24%, 95% CI 13 to 35); for profit status (-20%, 95% CI -26 to -14) compared with nonprofit, lowest trauma designation (+17%, 95% CI 5 to 30); teaching hospital status (+7%, 95% CI 1 to 14); highest number of inpatient beds (+13%, 95% CI 4 to 23); and Medicaid share versus quarter (Q)1 (Q2: -12%, 95% CI -18 to -7; Q3: -13%, 95% CI -19 to -7; Q4: -11%, 95% CI -17 to -4).

CONCLUSIONS

Our results suggest nonclinical factors are important drivers of pediatric health care costs.

Safely Shifting MRIs for Seizure Evaluation to the Outpatient Setting

BACKGROUND AND OBJECTIVES

When a patient is admitted for seizure-like activity, in addition to obtaining a thorough history and physical exam, the evaluation may include a neurology consultation, EEG, and brain MRI. The cost of an inpatient MRI is significant and only 2% of MRIs yield clinically significant findings. At our institution, there was a 20% increase in patients undergoing inpatient MRI from 2018 to 2020. Our aim: Decrease the percentage of patient encounters receiving inpatient brain MRIs for seizure evaluation from 50% to 40% in 6 months by safely shifting MRIs to the outpatient setting.

METHODS

Initially, provider variability in ordering practices of MRIs was analyzed. Stakeholders were gathered and a local guideline was developed to standardize MRI utilization. A process map was created and highlighted barriers to obtaining an outpatient MRI. A new standard process was developed that streamlined and automated processes, and reduced delays and reliance on patients' families.

RESULTS

Since implementation of the new clinical guideline, the percentage of inpatient MRIs ordered for patient encounters presenting with seizures and seizure-like episodes decreased from a mean of 50% to 26%. Significant reductions occurred for patients with complex febrile seizures, provoked but afebrile seizures, and unprovoked seizures. The MRI guideline recommendations were followed in 93% of encounters in the final 12 months. None of the patients who underwent outpatient MRI required readmission for acute findings.

CONCLUSIONS

In this project, the percentage of inpatient MRIs was safely decreased with the implementation of a clinical guideline and standardized process.

Defining Treatment Response for Clinical Trials of Pediatric Acute Asthma

BACKGROUND

An agreed-upon definition of treatment response for clinical trials of pediatric acute asthma does not exist, limiting meaningful comparisons among therapeutic interventions and advances in asthma management.

OBJECTIVE

To develop a consensus definition of treatment response for clinical trials of pediatric acute asthma.

METHODS

A multidisciplinary panel of 22 experts participated in a Web-based modified Delphi process to achieve consensus on a definition of treatment response. Round 1 consisted of closed- and open-ended questions in which panelists ranked measures of treatment response developed by literature review, suggested additional measures, and explained their responses. In rounds 2 and 3, panelists reviewed summary statistics of the panel's rating from prior rounds and reconsidered their rankings. In round 3, pairwise ranking was performed to determine the ranked importance of components. Consensus was defined as 70% or greater agreement among panelists choosing Likert-scale values of 1 to 6 (extremely unimportant to extremely important) and an interquartile range less than 2.

RESULTS

Drawing on results from the expert panel, we developed a definition of treatment response that includes Clinical Severity Score, need for additional therapies, and hospitalization. Clinical Severity Score encompassed most ranked criteria (eg, respiratory distress, wheeze) for a treatment response definition. Panelists recommended that a valid and pragmatic severity score be used consistently across institutions. Panelists also achieved consensus on the top 10 criteria that appropriately classify need for hospitalization.

CONCLUSIONS

This consensus definition of treatment response can be used in clinical trials of children with acute asthma to standardize outcome measurement and report meaningful outcomes.

Predictors of Acute Care Reutilization in Pediatric Patients With Amoxicillin-Associated Reactions

BACKGROUND

Amoxicillin-associated reactions (AARs) contribute to substantial health care utilization, with a reutilization rate of 10% in pediatric emergency department (ED) and urgent care (UC) settings.

OBJECTIVE

To identify predictors of ED/UC reutilization by examining patients' clinical features and providers' management of AARs.

METHODS

Through a retrospective chart review of 668 patients presenting with AARs over 2 years to the pediatric ED/UC, we examined clinical features associated with ED/UC reutilization, including rash phenotype, systemic symptoms (fever, angioedema, joint involvement, gastrointestinal symptoms), and providers' management (pharmacologic treatment and counseling). We then constructed a statistical model to predict ED/UC reutilization using stepwise backward model selection.

RESULTS

ED/UC reutilizers were more likely to be male (P = .008) and have fever (P = .0001), angioedema (P < .0001), joint involvement (P < .0001), and gastrointestinal symptoms (P = .0001) during their AAR course. Rash phenotypes differed between groups (P < .0001), as ED/UC reutilizers more frequently exhibited urticaria. However, there were no differences in clinical management between groups, including pharmacologic recommendations, at the initial ED/UC encounter. In addition, our statistical model identified younger patients <2 years of age as more likely to reutilize ED/UC resources if providers did not document specific return precautions (odds ratio, 3.6; 95% confidence interval, 1.7-7.7).

CONCLUSION

Recognition of clinical features and treatment gaps associated with ED/UC reutilization will guide interventions to optimize care in children presenting with AARs, such as improved anticipatory guidance and early allergy consultation. Prospective studies are needed to determine whether these interventions will reduce ED/UC reutilization and facilitate timely allergy testing.

Establishment of achievable benchmarks of care in the neurodiagnostic evaluation of simple febrile seizures

BACKGROUND

Current guidelines recommend against neurodiagnostic testing for the evaluation of simple febrile seizures.

OBJECTIVES

(1) Assess overall and institutional rates of neurodiagnostic testing and (2) establish achievable benchmarks of care (ABCs) for children evaluated for simple febrile seizures at children's hospitals.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study of children 6 months to 5 years evaluated in the emergency department (ED) 2016-2019 with simple febrile seizures at 38 children's hospitals in Pediatric Health Information System database. We excluded children with epilepsy, complex febrile seizures, complex chronic conditions, and intensive care.

OUTCOME MEASURES

Proportions of children who received neuroimaging, electroencephalogram (EEG), or lumbar puncture (LP) and rates of hospitalization for study cohort and individual hospitals. Hospital-specific outcomes were adjusted for patient demographics and severity of illness. We utilized hospital-specific values for each measure to calculate ABCs.

RESULTS

We identified 51,015 encounters. Among the study cohort 821 (1.6%) children had neuroimaging, 554 (1.1%) EEG, 314 (0.6%) LP, and 2023 (4.0%) were hospitalized. Neurodiagnostic testing rates varied across hospitals: neuroimaging 0.4%-6.7%, EEG 0%-8.2%, LP 0%-12.7% in patients <1-year old and 0%-3.1% in patients ≥1 year. Hospitalization rate ranged from 0%-14.5%. Measured outcomes were higher among hospitalized versus ED-only patients: neuroimaging 15.3% versus 1.0%, EEG% 24.7 versus 0.1% (p < .001). Calculated ABCs were 0.6% for neuroimaging, 0.1% EEG, 0% LP, and 1.0% hospitalization.

CONCLUSIONS

Rates of neurodiagnostic testing and hospitalization for simple febrile seizures were low but varied across hospitals. Calculated ABCs were 0%-1% for all measures, demonstrating that adherence to current guidelines is attainable.

Resource Utilization During Low-Acuity Pediatric Emergency Department Visits

OBJECTIVES

The aims of the study were to estimate testing and treatment rates among pediatric low-acuity emergency department (ED) visits and to compare testing and treatment patterns at general and pediatric-specific EDs.

METHODS

We performed a cross-sectional study of triage level 4 or 5 pediatric visits from a complex survey of nonfederal US EDs from 2008 to 2017. We analyzed demographics, vital signs, disposition, testing, and treatment. We calculated proportions for each data element and used χ2 tests to determine differences between general and pediatric EDs.

RESULTS

There were an estimated 306.2 million pediatric visits with 129.1 million acuity level 4 or 5 visits (57.2%; 95% confidence interval, 55.4%-58.9%), with diagnostic testing performed in 47.1% and medications administered in 69.6% of the visits. Most low-acuity visits (82.0%) were to general EDs. Tests performed more frequently in general EDs compared with pediatric EDs included radiographs (25.8% vs 15.7%, P < 0.01), complete blood count (6.4% vs 3.9%, P < 0.01), electrolytes (11.6% vs 3.7%, P < 0.01), and glucose (2.0% vs 0.9%, P < 0.01). Ultrasound was used less frequently in general EDs (0.5 vs 0.7, P < 0.01). There were similar rates of intravenous fluid and overall medication administration and a higher proportion of patients receiving antibiotics in general EDs (28.7% vs 23.8%, P < 0.01).

CONCLUSIONS

More than half of pediatric visits to the ED are low acuity. Although general EDs relied on more imaging, blood testing and antibiotics, and pediatric EDs on ultrasound, overall resource utilization was high in this population across both ED types and can likely be reduced.

Oral Ondansetron Administration in Children Seeking Emergency Department Care for Acute Gastroenteritis: A Patient-Level Propensity-Matched Analysis

STUDY OBJECTIVE

This study aimed to explore oral ondansetron usage and impact on outcomes in clinical practice.

METHODS

This observational study was a planned secondary analysis of 2 trials conducted in 10 US and 6 Canadian institutions between 2014 and 2017. Children 3 to 48 months old with gastroenteritis and ≥3 episodes of vomiting in the 24 hours preceding emergency department (ED) presentation were included. Oral ondansetron was administered at the discretion of the provider. The principal outcomes were intravenous fluid administration and hospitalization at the index visit and during the subsequent 72 hours and diarrhea and vomiting frequency during the 24 hours following the ED visit.

RESULTS

In total, 794 children were included. The median age was 16.0 months (interquartile range 10.0 to 26.0), and 50.1% (398/794) received oral ondansetron. In propensity-adjusted analysis (n=528), children administered oral ondansetron were less likely to receive intravenous fluids at the index visit (adjusted odds ratio [aOR] 0.50; 95% confidence interval [CI] 0.29 to 0.88). There were no differences in the frequencies of intravenous fluid administration within the first 72 hours (aOR 0.65; 95% CI 0.39 to 1.10) or hospitalization at the index visit (aOR 0.31; 95% CI 0.09 to 1.10) or the subsequent 72 hours (aOR 0.52; 95% CI 0.21 to 1.28). Episodes of vomiting (aRR 0.86; 95% CI 0.63 to 1.19) and diarrhea (aRR 1.11; 95% CI 0.93 to 1.32) during the 24 hours following ED discharge also did not differ.

CONCLUSION

Among preschool-aged children with gastroenteritis seeking ED care, oral ondansetron administration was associated with a reduction in index ED visit intravenous fluid administration; it was not associated with intravenous fluids administered within 72 hours, hospitalization, or vomiting and diarrhea in the 24 hours following discharge.

Provision of Guideline-Based Pediatric Asthma Care in US Emergency Departments

OBJECTIVES

National guidelines for routine pediatric acute asthma care recommend providing corticosteroids, and discourage routinely obtaining chest radiographs (CXRs) and using antibiotics. We examined rates of adherence to all 3 of these aspects during emergency department (ED) visits and compared performance between pediatric and general EDs.

METHODS

Using the National Hospital Ambulatory Medical Care Survey, we included all nontransfer ED visits for patients younger than 19 years with a diagnosis of asthma and treatment with albuterol from 2005 to 2015. Guideline-based care, defined as (1) corticosteroids, (2) no antibiotics, and (3) no CXR, was assessed for each visit. Hospitals were categorized as pediatric or general and compared according to rates of guideline-based care. Multivariable analyses were used to identify demographic and hospital-level characteristics associated with guideline-based care.

RESULTS

More than 7 million ED visits met eligibility criteria. Antibiotic provision and CXR acquisition were significantly higher in general EDs (20% vs 11%, 40% vs 26%, respectively), while steroid provision was similar (63% vs 62%). Overall, 34% of visits involved guideline-based care, with a higher rate for pediatric EDs compared with general EDs (42% to 31%). Visit at a pediatric ED (odds ratio, 1.62 [confidence interval 1.17-2.25]) and black race (odds ratio, 1.48 [confidence interval 1.07-2.02]) were independently associated with guideline-based care in a multivariate analysis.

CONCLUSIONS

Guideline-based care was more common in pediatric EDs, although only one-third of all pediatric-age visits met the definition of guideline-based care. Future policy and education efforts to reduce unnecessary antibiotic and CXR use for children with asthma are warranted.

Comparing Pediatric Gastroenteritis Emergency Department Care in Canada and the United States

BACKGROUND

Between-country variation in health care resource use and its impact on outcomes in acute care settings have been challenging to disentangle from illness severity by using administrative data.

METHODS

We conducted a preplanned analysis employing patient-level emergency department (ED) data from children enrolled in 2 previously conducted clinical trials. Participants aged 3 to <48 months with <72 hours of gastroenteritis were recruited in pediatric EDs in the United States (N = 10 sites; 588 participants) and Canada (N = 6 sites; 827 participants). The primary outcome was an unscheduled health care provider visit within 7 days; the secondary outcomes were intravenous fluid administration and hospitalization at or within 7 days of the index visit.

RESULTS

In adjusted analysis, unscheduled revisits within 7 days did not differ (adjusted odds ratio [aOR]: 0.72; 95% confidence interval (CI): 0.50 to 1.02). At the index ED visit, although participants in Canada were assessed as being more dehydrated, intravenous fluids were administered more frequently in the United States (aOR: 4.6; 95% CI: 2.9 to 7.1). Intravenous fluid administration rates did not differ after enrollment (aOR: 1.4; 95% CI: 0.7 to 2.8; US cohort with Canadian as referent). Overall, intravenous rehydration was higher in the United States (aOR: 3.8; 95% CI: 2.5 to 5.7). Although hospitalization rates during the 7 days after enrollment (aOR: 1.1; 95% CI: 0.4 to 2.6) did not differ, hospitalization at the index visit was more common in the United States (3.9% vs 2.3%; aOR: 3.2; 95% CI: 1.6 to 6.8).

CONCLUSIONS

Among children with gastroenteritis and similar disease severity, revisit rates were similar in our 2 study cohorts, despite lower rates of intravenous rehydration and hospitalization in Canadian-based EDs.

Predicting Severe Asthma Exacerbations in Children: Blueprint for Today and Tomorrow

Severe asthma exacerbations are the primary cause of morbidity and mortality in children with asthma. Accurate prediction of children at risk for severe exacerbations, defined as those requiring systemic corticosteroids, emergency department visit, and/or hospitalization, would considerably reduce health care utilization and improve symptoms and quality of life. Substantial progress has been made in identifying high-risk exacerbation-prone children. Known risk factors for exacerbations include demographic characteristics (ie, low income, minority race/ethnicity), poor asthma control, environmental exposures (ie, aeroallergen exposure/sensitization, concomitant viral infection), inflammatory biomarkers, genetic polymorphisms, and markers from other "omic" technologies. The strongest risk factor for a future severe exacerbation remains having had one in the previous year. Combining risk factors into composite scores and use of advanced predictive analytic techniques such as machine learning are recent methods used to achieve stronger prediction of severe exacerbations. However, these methods are limited in prediction efficiency and are currently unable to predict children at risk for impending (within days) severe exacerbations. Thus, we provide a commentary on strategies that have potential to allow for accurate and reliable prediction of children at risk for impending exacerbations. These approaches include implementation of passive, real-time monitoring of impending exacerbation predictors, use of population health strategies, prediction of severe exacerbation responders versus nonresponders to conventional exacerbation management, and considerations for preschool-age children who can be especially high risk. Rigorous prediction and prevention of severe asthma exacerbations is needed to advance asthma management and improve the associated morbidity and mortality.

Resource Use by Hospital Type for Frequent Inpatient Pediatric Conditions

BACKGROUND

Children's hospitals (CHs) deliver care to underserved, critically ill, and medically complex patients. However, non-CHs care for the majority of children with frequently occurring conditions. In this study, we aimed to examine resource use across hospitals where children receive care for frequent inpatient conditions.

METHODS

This was a cross-sectional, observational analysis of pediatric hospitalizations for 8 frequent inpatient conditions (pneumonia, asthma, bronchiolitis, mood disorders, appendicitis, epilepsy, skin and soft tissue infections, and fluid and electrolyte disorders) in the 2016 Kids' Inpatient Database. Primary outcomes were median length of stay (LOS) and median total cost. The primary independent variable was hospital type: nonchildren's, nonteaching; nonchildren's, teaching (NCT); and freestanding CHs. Multivariable linear regression was used to assess differences in mean LOS and costs.

RESULTS

There were 354 456 pediatric discharges for frequent inpatient conditions. NCT hospitals cared for more than one-half of all frequent inpatient conditions. CHs and NCT hospitals cared for the majority of patients with higher illness severity and medical complexity. After controlling for patient and hospital factors, discharges for frequent inpatient conditions at CHs had 0.48% longer mean LOS and 61% greater costs compared with NCT hospitals (P < .01).

CONCLUSIONS

CHs revealed higher estimated costs in caring for frequent inpatient conditions despite controlling for patient- and hospital-level factors but also cared for higher illness severity and medical complexity. Further research is warranted to explore whether we lack sufficient measures to control for patient-level factors and whether higher costs are justified by the specialized care at CHs.

Factors Associated With First Medication Time for Children Treated in the Emergency Department for Asthma

OBJECTIVES

Acute asthma exacerbations are among the most common reasons for childhood emergency department (ED) visits and hospitalizations. Although early ED administration of asthma medication has been shown to decrease hospitalizations, studies of factors associated with early ED asthma medication delivery have been limited. The objective of our study was to identify patient- and ED-related factors associated with early medication delivery among children treated in the ED for asthma exacerbations.

METHODS

This retrospective study used electronic health record data from all encounters for a primary diagnosis of asthma in an academic children's hospital ED during the study period 2009 to 2013. Using multivariate logistic regression, we identified the association between patient- and ED-related factors and the time to first medication defined as a binary outcome using a threshold of 1 hour from ED arrival. We then stratified our analysis by triage level (Emergency Severity Index [ESI]).

RESULTS

Of the 4846 encounters during the study period, 62% were male, mean age was 7.30 years, 76% had public insurance, and 57% had an ESI level of 3. Medication was administered within 1 hour of arrival in 2236 encounters (46%). After adjusting for covariates, multivariate logistic regression revealed that patients were less likely to have medications within 1 hour when they had less severe ESI (ESI 2 vs ESI 4: odds ratio [OR], 0.139; confidence interval [CI], 0.114-0.170), arrived via non-emergency medical services (OR, 0.525; CI, 0.413-0.665), or arrived to a crowded ED (OR, 0.574; CI, 0.505-0.652). Age, sex, and insurance type were not associated with timeliness of initial medication administration. Stratified analyses demonstrated that the crowding effect was larger for less severely ill patients.

CONCLUSIONS

Our study found that patient severity (acuity level, arrival mode) and level of ED crowing-but not demographic factors-are associated with the administration of medication in the first hour to pediatric patients with asthma. Our findings may be helpful in redesigning asthma care management strategies.

Long-term Effects of an Evidence-based Guideline for Emergency Management of Pediatric Syncope

Supplemental Digital Content is available in the text.

Variability exists in the management of childhood syncope as clinicians balance resource utilization with the need to identify serious diseases. Limited evidence exists regarding the long-term impact of evidence-based guidelines (EBGs) on clinical practices. This study’s objective was to measure long-term changes in the management of syncope after implementing a syncope EBG in a single pediatric emergency department following the redistribution of resources to facilitate compliance over time.

Management of children visiting the emergency department during out-of-office hours: an observational study

BACKGROUND

The aim was to study the characteristics and management of children visiting the emergency department (ED) during out-of-office hours.

METHODS

We analysed electronic health record data from 119 204 children visiting one of five EDs in four European countries. Patient characteristics and management (diagnostic tests, treatment, hospital admission and paediatric intensive care unit admission) were compared between children visiting during office hours and evening shifts, night shifts and weekend day shifts. Analyses were corrected for age, gender, Manchester Triage System urgency, abnormal vital signs, presenting problems and hospital.

RESULTS

Patients presenting at night were younger (median (IQR) age: 3.7 (1.4-8.2) years vs 4.8 (1.8-9.9)), more often classified as high urgent (16.3% vs 9.9%) and more often had ≥2 abnormal vital signs (22.8% vs 18.1%) compared with office hours. After correcting for disease severity, laboratory and radiological tests were less likely to be requested (adjusted OR (aOR): 0.82, 95% CI 0.78-0.86 and aOR: 0.64, 95% CI 0.60-0.67, respectively); treatment was more likely to be undertaken (aOR: 1.56, 95% CI 1.49-1.63) and patients were more likely to be admitted to the hospital (aOR: 1.32, 95% CI 1.24-1.41) at night. Patterns in management during out-of-office hours were comparable between the different hospitals, with variability remaining.

CONCLUSIONS

Children visiting during the night are relatively more seriously ill, highlighting the need to keep improving emergency care on a 24-hour-a-day basis. Further research is needed to explain the differences in management during the night and how these differences affect patient outcomes.

Implementing Pediatric Asthma Pathways in Community Hospitals: A National Qualitative Study

BACKGROUND

Pathways can improve the quality of care and outcomes for children with asthma; however, we know little about how to successfully implement pathways across diverse hospital settings. Prior studies of pathways have focused on determining clinical effectiveness and the majority were conducted in children's hospitals. These approaches have left crucial gaps in our understanding of how to successfully implement pathways in community hospitals, where most of the children with asthma are treated nationally.

OBJECTIVE

The aim of this study was to identify the key determinants of successful pediatric asthma pathway implementation in community hospitals.

METHODS

We conducted a qualitative study of healthcare providers that served as project leaders in a national collaborative to improve pediatric asthma care. Data were collected by recording semi-structured discussions between project leaders and external facilitators (EF) from December 2017 to April 2018. Using inductive thematic analysis, we identified the themes that describe the key determinants of pathway implementation.

RESULTS

Project leaders (n = 32) from 18 hospitals participated in this study. The key determinants of pathway implementation in community hospitals included (1) building an implementation infrastructure (eg, forming a team of local champions, modifying clinical workflows, delivering education/skills training), (2) engaging and motivating providers (eg, obtaining project buy-in, facilitating multidisciplinary collaboration, handling conflict), (3) addressing organizational and resource limitations (eg, support for electronic medical record integration), and (4) devising implementation solutions with EFs (eg, potential workflow modifications).

CONCLUSIONS

Our identification of the key determinants of pathway implementation may help guide pediatric quality improvement efforts in community hospitals. EFs may play an important role in successfully implementing pathways in community settings.

Internet search query data improve forecasts of daily emergency department volume

OBJECTIVE

Emergency departments (EDs) are increasingly overcrowded. Forecasting patient visit volume is challenging. Reliable and accurate forecasting strategies may help improve resource allocation and mitigate the effects of overcrowding. Patterns related to weather, day of the week, season, and holidays have been previously used to forecast ED visits. Internet search activity has proven useful for predicting disease trends and offers a new opportunity to improve ED visit forecasting. This study tests whether Google search data and relevant statistical methods can improve the accuracy of ED volume forecasting compared with traditional data sources.

MATERIALS AND METHODS

Seven years of historical daily ED arrivals were collected from Boston Children's Hospital. We used data from the public school calendar, National Oceanic and Atmospheric Administration, and Google Trends. Multiple linear models using LASSO (least absolute shrinkage and selection operator) for variable selection were created. The models were trained on 5 years of data and out-of-sample accuracy was judged using multiple error metrics on the final 2 years.

RESULTS

All data sources added complementary predictive power. Our baseline day-of-the-week model recorded average percent errors of 10.99%. Autoregressive terms, calendar and weather data reduced errors to 7.71%. Search volume data reduced errors to 7.58% theoretically preventing 4 improperly staffed days.

DISCUSSION

The predictive power provided by the search volume data may stem from the ability to capture population-level interaction with events, such as winter storms and infectious diseases, that traditional data sources alone miss.

CONCLUSIONS

This study demonstrates that search volume data can meaningfully improve forecasting of ED visit volume and could help improve quality and reduce cost.

Trends in United States emergency department visits and associated charges from 2010 to 2016

BACKGROUND

Demographic shifts and care delivery system evolution affect the number of Emergency Department (ED) visits and associated costs. Recent aggregate trends in ED visit rates and charges between 2010 and 2016 have not been evaluated.

METHODS

Data from the National Emergency Department Sample, comprising approximately 30 million annual patient visits, were used to estimate the ED visit rate and charges per visit from 2010 to 2016. ED visits were grouped into 144 mutually exclusive clinical categories. Visit rates, compound annual growth rates (CAGRs), and per visit charges were estimated.

RESULTS

From 2010 to 2016, the number of ED visits increased from 128.97 million to 144.82 million; the cumulative growth was 12.29% and the CAGR was 1.95%, while the population grew at a CAGR of 0.73%. Expressed as a population rate, ED visits per 1000 persons increased from 416.92 in 2010 to 448.19 in 2016 (p value <0.001). The mean charges per visit increased from $2061 (standard deviation $2962) in 2010 to $3516 (standard deviation $2962) in 2016; the CAGR was 9.31% (p value <0.001). Of 144 clinical categories, 140 categories had a CAGR for mean charges per visit of at least 5%.

CONCLUSION

The rate of ED visits per 1000 persons and the mean charge per ED visit increased significantly between 2010 and 2016. Mean charges increased for both high- and low-acuity clinical categories. Visits for the 5 most common clinical categories comprise about 30% of ED visits, and may represent focus areas for increasing the value of ED care.

Repeat Emergency Department Visits for Individuals With Intellectual and Developmental Disabilities and Psychiatric Disorders

Although individuals with intellectual and developmental disabilities (IDD) and psychiatric concerns are more likely than others to visit hospital emergency departments (EDs), the frequency of their returns to the ED within a short time is unknown. In this population-based study we examined the likelihood of this group returning to the ED within 30 days of discharge and described these visits for individuals with IDD + psychiatric disorders (n = 3,275), and persons with IDD only (n = 1,944) compared to persons with psychiatric disorders only (n = 41,532). Individuals with IDD + psychiatric disorders, and individuals with IDD alone were more likely to make 30-day repeat ED visits. Improving hospital care and postdischarge community linkages may reduce 30-day returns to the ED among adults with IDD.

Racial/Ethnic Variation in Emergency Department Care for Children With Asthma

OBJECTIVE

To assess the variation between racial/ethnic groups in emergency department (ED) treatment of asthma for pediatric patients.

METHODS

This study was a cross-sectional analysis of pediatric (2-18 years) asthma visits among 6 EDs in the Upper Midwest between June 2011 and May 2012. We used mixed-effects logistic regression to assess the odds of receiving steroids, radiology tests, and returning to the ED within 30 days. We conducted a subanalysis of asthma visits where patients received at least 1 albuterol treatment in the ED.

RESULTS

The sample included 2909 asthma visits by 1755 patients who were discharged home from the ED. After adjusting for demographics, insurance type, and triage score, African American (adjusted odds ratio [aOR], 1.78; 95% confidence interval [CI], 1.40-2.26) and Hispanic (aOR, 1.64; 95% CI, 1.22-2.22) patients had higher odds of receiving steroids compared with whites. African Americans (aOR, 0.58; 95% CI, 0.46-0.74) also had lower odds of radiological testing compared with whites. Asians had the lowest odds of 30-day ED revisits (aOR, 0.26; 95% CI, 0.08-0.84), with no other significant differences detected between racial/ethnic groups. Subgroup analyses of asthma patients who received albuterol revealed similar results, with American Indians showing lower odds of radiological testing as well (aOR, 0.47; 95% CI, 0.22-1.01).

CONCLUSIONS

In this study, children from racial/ethnic minority groups had higher odds of steroid administration and lower odds of radiological testing compared with white children. The underlying reasons for these differences are likely multifactorial, including varying levels of disease severity, health literacy, and access to care.

Epidemiology and Resource Utilization of Simple Febrile Seizure-associated Hospitalizations in the United States, 2003-2012

BACKGROUND

Simple febrile seizure (SFS) affects 2% to 4% of children under 6 years of age. The purpose of this study is to examine the epidemiologic patterns and resource utilization of SFS-associated hospitalizations in children aged younger than 6 years of age in the United States.

MATERIALS AND METHODS

This study is a serial, retrospective analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Databases for the years 2003, 2006, 2009, and 2012. SFS-associated hospitalizations were identified based on International Classification of Diseases, Ninth Revision, Clinical Modification, diagnosis code 780.31. We calculated the proportion of hospitalizations in pediatric patients under 6 years of age due to SFS and all other nonbirth causes, the rate of SFS-associated hospitalizations per 100,000 population, the mean length of stay and inflation-adjusted hospital costs of SFS-associated hospitalizations, as well as patient demographics and hospital characteristics.

RESULTS

From 2003 to 2012, the weighted proportion of hospitalizations due to SFS declined from 0.83% to 0.41% (P<0.01) and the annual rate of SFS-associated hospitalizations per 100,000 population decreased from 48.0 to 18.7 (P<0.01). However, use of computed tomography, electroencephalogram, and lumbar puncture in SFS-associated hospitalizations decreased significantly (all P<0.001), but the utilization rate of magnetic resonance imaging remained stable (P=0.53). The mean length of stay for SFS-associated hospitalizations decreased from 2.03 days in 2003 to 1.74 days in 2012, and the mean hospital costs (exclusive of professional payment) decreased from $3830 in 2003 to $3223 in 2012 (both P<0.001).

CONCLUSIONS

SFS-associated hospitalizations and resource utilization in children under 6 years of age have decreased markedly in the United States, probably due to improved clinical adherence to the practice parameters set forth by the American Academy of Pediatrics for managing patients with SFS.

Variation in Pediatric Care Between Academic and Nonacademic US Emergency Departments, 1995-2010

OBJECTIVES

The aim of this study was to describe the resource utilization for children with common pediatric conditions treated in academic and nonacademic emergency departments (EDs).

METHODS

We performed a retrospective, cross-sectional descriptive study using the National Hospital Ambulatory Medical Care Survey Data from 1995 to 2010 including children less than 18 years old with a diagnosis of asthma, bronchiolitis, croup, gastroenteritis, fever, febrile seizure, or afebrile seizure. Academic EDs (A-ED) were those with greater than 25% of patients seen by a trainee. For each condition, we reported the proportion of testing, medications, and disposition between A-ED and nonacademic EDs (NA-ED).

RESULTS

From 1995 to 2010, approximately 450,000,000 estimated pediatric visits are represented by the survey based on 122,811 actual visits. For most common conditions, testing and disposition were comparable; however, some variation was noted. Among patients with bronchiolitis, a higher proportion of patients was admitted and had radiographs in NA-EDs (18% vs 10% and 56% vs 45%, respectively). For children with croup, radiographs were performed more often at NA-EDs (27% vs 6%). Among those with febrile seizures, more lumbar punctures were performed in NA-EDs (14% vs 0%). In children with afebrile seizures, more head computed tomography scans were obtained at NA-EDs (34% vs 21%).

CONCLUSION

Among pediatric patients with croup, bronchiolitis, and febrile and afebrile seizure, higher resource utilization and admissions were observed in NA-EDs. These preliminary findings from a national survey require a more detailed investigation into the variation in care between A-ED and NA-ED settings.

Return Visit Admissions May Not Indicate Quality of Emergency Department Care for Children

OBJECTIVE

The objective was to test the hypothesis that in-hospital outcomes are worse among children admitted during a return ED visit than among those admitted during an index ED visit.

METHODS

This was a retrospective analysis of ED visits by children age 0 to 17 to hospitals in Florida and New York in 2013. Children hospitalized during an ED return visit within 7 days were classified as "ED return admissions" (discharged at ED index visit and admitted at return visit) or "readmissions" (admission at both ED index and return visits). In-hospital outcomes for ED return admissions and readmissions were compared to "index admissions without return admission" (admitted at ED index visit without 7-day return visit admission).

RESULTS

Among 1,886,053 index ED visits to 321 hospitals, 75,437 were index admissions without return admission, 7,561 were ED return admissions, and 1,333 were readmissions. ED return admissions had lower intensive care unit admission rates (11.0% vs. 13.6%; adjusted odds ratio = 0.78; 95% confidence interval [CI] = 0.71 to 0.85), longer length of stay (3.51 days vs. 3.38 days; difference = 0.13 days; incidence rate ratio = 1.04; 95% CI = 1.02 to 1.07), but no difference in mean hospital costs (($7,138 vs. $7,331; difference = -$193; 95% CI = -$479 to $93) compared to index admissions without return admission.

CONCLUSIONS

Compared with children who experienced index admissions without return admission, children who are initially discharged from the ED who then have a return visit admission had lower severity and similar cost, suggesting that ED return visit admissions do not involve worse outcomes than do index admissions.

Direct concurrent comparison of multiple pediatric acute asthma scoring instruments

OBJECTIVE

Appropriate delivery of Emergency Department (ED) treatment to children with acute asthma requires clinician assessment of acute asthma severity. Various clinical scoring instruments exist to standardize assessment of acute asthma severity in the ED, but their selection remains arbitrary due to few published direct comparisons of their properties. Our objective was to test the feasibility of directly comparing properties of multiple scoring instruments in a pediatric ED.

METHODS

Using a novel approach supported by a composite data collection form, clinicians categorized elements of five scoring instruments before and after initial treatment for 48 patients 2-18 years of age with acute asthma seen at the ED of a tertiary care pediatric hospital ED from August to December 2014. Scoring instruments were compared for inter-rater reliability between clinician types and their ability to predict hospitalization.

RESULTS

Inter-rater reliability between clinician types was not different between instruments at any point and was lower (weighted kappa range 0.21-0.55) than values reported elsewhere. Predictive ability of most instruments for hospitalization was higher after treatment than before treatment (p < 0.05) and may vary between instruments after treatment (p = 0.054).

CONCLUSIONS

We demonstrate the feasibility of comparing multiple clinical scoring instruments simultaneously in ED clinical practice. Scoring instruments had higher predictive ability for hospitalization after treatment than before treatment and may differ in their predictive ability after initial treatment. Definitive conclusions about the best instrument or meaningful comparison between instruments will require a study with a larger sample size.

Improving Timeliness of β-Agonist and Corticosteroid Administration in Patients With Acute Wheezing

OBJECTIVE

Timely delivery of β-agonists and steroids to patients with acute recurrent wheezing is a key component of the National Heart, Lung, and Blood Institute recommended emergency department (ED) asthma care. We conducted an ED improvement initiative to standardize asthma care and improve time to treatments.

METHODS

Our multidisciplinary team identified key contributing factors to timeliness, developed key driver diagrams, implemented and refined a management pathway, designed and executed rapid cycle improvements, and implemented interventions. A time series design was used to analyze outcomes with baseline data and continuous monitoring during active intervention steps. The primary outcomes analyzed were the times to first β-agonist and steroid administration. Secondary outcomes included admission rate, ED length of stay, and ED revisits.

RESULTS

Assignment of the Pediatric Asthma Score, our initial pathway step, occurred in most patients within the first several months. Time to first β-agonist administration decreased from the baseline mean of 76 minutes to 27 minutes. Time to steroid administration decreased from the baseline mean of 108 minutes to 49 minutes. Mean monthly admission rate remained at 22% with no special cause variation identified. The ED revisit rate was not negatively impacted and, in most months, was 0%.

CONCLUSIONS

By standardizing asthma care in our ED and redesigning care delivery processes, care variation decreased and significant improvements in timeliness of β-agonist and steroid administration occurred.

Practice Variation and Effects of E-mail-only Performance Feedback on Resource Use in the Emergency Department

OBJECTIVES

Higher resource utilization in the management of pediatric patients with undifferentiated vomiting and/or diarrhea does not correlate consistently with improved outcomes or quality of care. Performance feedback has been shown to change physician practice behavior and may be a mechanism to minimize practice variation. We aimed to evaluate the effects of e-mail-only, provider-level performance feedback on the ordering and admission practice variation of pediatric emergency physicians for patients presenting with undifferentiated vomiting and/or diarrhea.

METHODS

We conducted a prospective, quality improvement intervention and collected data over 3 consecutive fiscal years. The setting was a single, tertiary care pediatric emergency department. We collected admission and ordering practices data on 19 physicians during baseline, intervention, and postintervention periods. We provided physicians with quarterly e-mail-based performance reports during the intervention phase. We measured admission rate and created four categories for ordering practices: no orders, laboratory orders, pharmacy orders, and radiology orders.

RESULTS

There was wide (two- to threefold) practice variation among physicians. Admission rates ranged from 15% to 30%, laboratory orders from 19% to 43%, pharmacy orders from 29% to 57%, and radiology orders from 11% to 30%. There was no statistically significant difference in the proportion of patients admitted or with radiology or pharmacy orders placed between preintervention, intervention, or postintervention periods (p = 0.58, p = 0.19, and p = 0.75, respectively). There was a significant but very small decrease in laboratory orders between the preintervention and postintervention periods.

CONCLUSIONS

Performance feedback provided only via e-mail to pediatric emergency physicians on a quarterly basis does not seem to significantly impact management practices for patients with undifferentiated vomiting and/or diarrhea.

Comparing Practice Patterns Between Pediatric and General Emergency Medicine Physicians: A Scoping Review

OBJECTIVE

Acutely ill infants and children presenting to the emergency department are treated by either physicians with pediatric emergency medicine (PEM) training or physicians without PEM training, a good proportion of which are general emergency medicine-trained physicians (GEDPs). This scoping review identified published literature comparing the care provided to infants and children (≤21 years of age) by PEM-trained physicians to that provided by GEDPs.

METHODS

The search was conducted in 2 main steps as follows: (1) initial literature search to identify available literature with evolving feedback from the group while simultaneously deciding search concepts as well as inclusion and exclusion criteria and (2) modification of search concepts and conduction of search using finalized concepts as well as review and selection of articles for final analysis using set inclusion criteria. Each study was independently assessed by 2 reviewers for eligibility and quality. Data were independently abstracted by reviewers, and authors were contacted for missing data.

RESULTS

Our search yielded 3137 titles and abstracts. Twenty articles reporting 19 studies were included in the final analysis. The studies were grouped under type of care, diagnostic studies, medication administration, and process of care. The studies addressed differences in the management of fever, croup, bronchiolitis, asthma, urticaria, febrile seizures, and diabetic ketoacidosis.

CONCLUSIONS

This review highlights the lack of robust studies and heterogeneity of literature comparing practice patterns of PEM-trained physicians with GEDPs. We have outlined a systematic approach to reviewing a body of literature for topics that lack clear terms of comparison across studies.

Improving Pediatric Asthma Outcomes in a Community Emergency Department

BACKGROUND

Asthma triggers >775 000 emergency department (ED) visits for children each year. Approximately 80% of these visits occur in community EDs. We performed this study to measure effects of partnership with a community ED on pediatric asthma care.

METHODS

For this quality improvement initiative, we implemented an evidence-based pediatric asthma guideline in a community ED. We included patients whose clinical impression in the medical decision section of the electronic health record contained the words asthma, bronchospasm, or wheezing. We reviewed charts of included patients 12 months before guideline implementation (August 2012-July 2013) and 19 months after guideline implementation (August 2013-February 2015). Process measures included the proportion of children who had an asthma score recorded, the proportion who received steroids, and time to steroid administration. The outcome measure was the proportion of children who needed transfer for additional care.

RESULTS

In total, 724 patients were included, 289 during the baseline period and 435 after guideline implementation. Overall, 64% of patients were assigned an asthma score after guideline implementation. During the baseline period, 60% of patients received steroids during their ED visit, compared with 76% after guideline implementation (odds ratio 2.2; 95% confidence interval, 1.6-3.0). After guideline implementation, the mean time to steroids decreased significantly, from 196 to 105 minutes (P < .001). Significantly fewer patients needed transfer after guideline implementation (10% compared with 14% during the baseline period) (odds ratio 0.63; 95% confidence interval, 0.40-0.99).

CONCLUSIONS

Our study shows that partnership between a pediatric tertiary care center and a community ED is feasible and can improve pediatric asthma care.

Clinical Practice Guideline for the Treatment of Pediatric Acute Gastroenteritis in the Outpatient Setting

Acute gastroenteritis (AGE) is a common illness in childhood that usually can be treated in the outpatient setting. Inaccurate assessment or delayed treatment of AGE can lead to an increased risk for invasive interventions. A literature search was conducted using PubMed, CINAHL Plus, the Cochrane Library, and Embase. Results of the query were refined to narrow the focus of relevant studies for the provider caring for dehydrated children in the outpatient setting. Use of clinical dehydration scales to assess the level of dehydration and early initiation of oral rehydration therapy promote optimal patient outcomes. Oral rehydration therapy remains the best means of rehydrating, and ondansetron is a safe and effective adjunct to help children with persistent vomiting. The purpose of this practice guideline is to identify best practices for AGE in children older than 6 months with symptoms for less than 7 days who are being cared for in the outpatient setting.

Ondansetron for pediatric concussion; a pilot study for a randomized controlled trial

Objectives

Assess the feasibility of a study evaluating one dose of oral ondansetron to decrease post-concussion symptoms at one week and one month following concussion in children aged 8 to 17 years old.

Method

This was a pilot study for a randomized, triple-blind controlled trial of one dose of either ondansetron or placebo performed in a tertiary care pediatric emergency department. Participants were children aged 8 to 17 years who sustained a concussion in the previous 24 hours and visited a single emergency department. The outcome of interest was an increase from pre-concussion baseline of at least 3 symptoms from the Post-Concussion Symptom Inventory, measured at one week and at one month following concussion. The primary outcome was to determine the proportion of children who completed the assessment at one week following the intervention. Secondary outcome was the proportion of children who completed the assessment at one month following the intervention. All children, care givers, and those assessing the outcomes were blinded to the group assignment.

Results

Of the 218 children presenting with a concussion during the study period, we screened 108 and found 36/108 (33%) eligible to participate and 16/108 (14.8%) agreed to participate. All enrolled patients were compliant with the intervention and follow-up.

Conclusion

In our study population, approximately one-third of the screened concussion patients were eligible to participate and approximately one half of those eligible agreed to participate. Our study found that most enrolled patients preferred electronic follow-up; the noncompliance rate was minimal.

Essentials of PEM Fellowship: Part 5: Scholarship Prepares Fellows to Lead as Pediatric Emergency Specialists

OBJECTIVE

The aim of this article was to discuss the current landscape in pediatric emergency medicine fellowship training for scholarship training and provide an overview of the resources and general strategies required to prepare fellows for their careers.

OVERVIEW

This article is the fifth in a 7-part series that aims to comprehensively describe the current state and future directions of pediatric emergency medicine fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated upon program completion. This article focuses on scholarship training.

Characteristics of Children With Cancer Discharged or Admitted From the Emergency Department

BACKGROUND

Emergency department (ED) utilization by children with cancer is poorly understood. Among children with cancer, we explored reasons for ED visits and factors associated with admission within U.S. children's hospitals.

METHODS

A retrospective study of the 2011-2013 Pediatric Health Information System (PHIS) was conducted. Eligible ED visits included those within 365 days from the first inpatient encounter with an International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) code for cancer. Patient characteristics and reasons for ED visits were assessed. Factors associated with admission from the ED were examined with multivariable regression.

RESULTS

There were 26,770 ED visits by 17,943 children with cancer at 39 children's hospitals during the study period. Half of children with cancer visited the ED within 1 year after their first cancer hospitalization in PHIS. Fifty-six percent of ED visits resulted in admission. Fever or neutropenia accounted for the largest proportion of reasons for visits (34.6%). Risk factors for admission were as follows: "Other" race/ethnicity as compared to white, non-Hispanic (odds ratio [OR] = 1.4, 95% confidence interval [CI] 1.2-1.6), history of transplant (OR = 1.7, 95% CI 1.4-2.1), and ED visits reasons including neutropenia (OR = 43.4, 95% CI 36.0-52.3), blood stream infection (OR = 3.3, 95% CI 2.8-3.9), pancytopenia (OR = 28.8, 95% CI 18.1-45.9), dehydration (OR = 2.3, 95% CI 1.9-2.9), or pneumonia (OR = 3.8, 95% CI 2.8-5.1).

CONCLUSIONS

Children with cancer have high ED usage within 1 year after their first cancer hospitalization. Age, demographic factors, and reasons for ED visits significantly impacted admission from the ED. Further research should focus on ED utilization among children with cancer.

Variation and Trends in Anaphylaxis Care in United States Children's Hospitals

OBJECTIVES

We sought to determine the extent of variation in treatment of children with anaphylaxis.

METHODS

We identified children 1 month to 18 years of age presenting with a primary diagnosis of anaphylaxis to one of the 35 pediatric hospitals included in the Pediatric Health Information System between January 1, 2009, and September 30, 2013. We evaluated the variation in use of β2 agonists, glucocorticoids, histamine-1 (H1) antagonists, histamine-2 (H2) antagonists, inhaled epinephrine, intravenous fluids, and oxygen. We assessed whether variation exists in the rates of hospitalization and 3-day emergency department (ED) revisits and whether a temporal trend exists in the ED visit rate for anaphylaxis.

RESULTS

Among 10,351 children with anaphylaxis, the hospital-level median use of common anaphylaxis therapies varied for β2 agonists (22%, interquartile range [IQR] = 16%-26%), glucocorticoids (71%, IQR = 65%-76%), H1 blockers (60%, IQR = 57%-65%), H2 blockers (53%, IQR = 36%-64%), inhaled epinephrine (2.2%, IQR = 1.3%-3.5%), intravenous fluids (26%, IQR = 13%-41%), and oxygen (2.6%, IQR = 0.8%-4.1%). Hospitalization rates ranged from 12% to 95%, with a median rate of 41%. Anaphylaxis diagnoses rose from 5.7 to 11.7 patients per 10,000 ED visits between 2009 and 2013 (p < 0.001 for trend).

CONCLUSIONS

There is substantial variability in the use of common therapies and hospitalization rates for children cared for in U.S. children's hospitals. Additionally, ED visits for children with anaphylaxis are increasing at U.S. children's hospitals. These findings highlight the need for research defining optimal care for anaphylaxis.

Quality in paediatric emergency medicine: Measurement and reporting

There is a clear demand for quality in the delivery of health care around the world; paediatric emergency medicine is no exception to this movement. It has been identified that gaps exist in the quality of acute care provided to children. Regulatory bodies in Australia and New Zealand are moving to mandate the implementation of quality targets and measures. Within the paediatric emergency department (ED), there is a lack of research into paediatric specific indicators. The existing literature regarding paediatric acute care quality measures has been recently summarised, and expert consensus has now been reported. It is clear that there is much work to be performed to generalise this work to ED. We review suggestions from the current literature relating to feasible indicators within the paediatric acute care setting. We propose options to develop a quality 'scorecard' that could be used to assist Australian and New Zealand EDs with quality measurement and benchmarking for their paediatric patients.

Clinical pathway improves pediatrics asthma management in the emergency department and reduces admissions

OBJECTIVE

Poor adherence to the National Institute of Health (NIH) Asthma Guidelines may result in unnecessary admissions for children presenting to the emergency department (ED) with exacerbations. We determine the effect of implementing an evidence-based ED clinical pathway on corticosteroid and bronchodilator administration and imaging utilization, and the subsequent effect on hospital admissions in a US ED.

METHODS

A prospective, interventional study of pediatric (≤21 years) visits to an academic ED between 2011 and 2013 with moderate-severe asthma exacerbations has been conducted. A multidisciplinary team designed a one-page clinical pathway based on the NIH Guidelines. Nurses, respiratory therapists and physicians attended educational sessions prior to the pathway implementation. By adjusting for demographics, acuity and ED volume, we compared timing and appropriateness of corticosteroid and bronchodilator administration, and chest radiograph (CXR) utilization with historical controls from 2006 to 2011. Subsequent hospital admission rates were also compared.

RESULTS

A total of 379 post-intervention visits were compared with 870 controls. Corticosteroids were more likely to be administered during post-intervention visits (96% vs. 78%, adjusted OR 6.35; 95% CI 3.17-12.73). Post-intervention, median time to corticosteroid administration was 45 min faster (RR 0.74; 95% CI 0.67-0.81) and more patients received corticosteroids within 1 h of arrival (45% vs. 18%, OR 3.5; 95% CI 2.50-4.90). More patients received > 1 bronchodilator dose within 1 h (36% vs. 24%, OR 1.65; 95% CI 1.23-2.21) and fewer received CXRs (27% vs. 42%, OR 0.7; 95% CI 0.52-0.94). There were fewer admissions post-intervention (13% vs. 21%, OR 0.53; 95% CI 0.37-0.76).

CONCLUSION

A clinical pathway is associated with improved adherence to NIH Guidelines and, subsequently, fewer hospital admissions for pediatric ED patients with asthma exacerbations.

Variation in the use of procedural sedation for incision and drainage of skin and soft tissue infection in pediatric emergency departments

OBJECTIVES

Little is known about procedural sedation use for anxiety and pain associated with skin and soft tissue infections (SSTIs) requiring incision and drainage (I&D). Our objectives were therefore (1) to characterize the use of procedural sedation use for SSTI I&D procedures in pediatric emergency departments (EDs), (2) to compare the frequency of procedural sedation for I&D across hospitals, and (3) to determine factors associated with use of procedural sedation for I&D.

METHODS

We performed a retrospective cohort study of pediatric EDs contributing to the Pediatric Health Information Systems database in 2010. Cases were identified by primary International Classification of Diseases, 9th revision, Clinical Modification procedure codes for I&D. We used descriptive statistics to describe procedural sedation use across hospitals and logistic generalized linear mixed models to identify factors associated with use of procedural sedation.

RESULTS

There were 6322 I&D procedures, and procedural sedation was used in 24% of cases. Hospital-level use of procedural sedation varied widely, with a range of 2% to 94% (median 17%). Procedural sedation use was positively associated with sensitive body site, female gender, and employer-based insurance, and negatively associated with African American race and increasing age. Estimates of hospital-level use of procedural sedation for a referent case eliminating demographic differences exhibit similar variability with a range of 5% to 97% (median 34%).

CONCLUSIONS

Use of procedural sedation for SSTI I&D varies widely across pediatric EDs, and the majority of variation is independent of demographic differences. Additional work is needed to understand decision-making and to standardize delivery of procedural sedation in children requiring I&D.

Impact of Physician Scorecards on Emergency Department Resource Use, Quality, and Efficiency

BACKGROUND AND OBJECTIVES

Variability in practice patterns and resource use in the emergency department (ED) can affect costs without affecting outcomes. ED quality measures have not included resource use in relation to ED outcomes and efficiency. Our objectives were to develop a tool for comprehensive physician feedback on practice patterns relative to peers and to study its impact on resource use, quality, and efficiency.

METHODS

We evaluated condition-specific resource use (laboratory tests; imaging; antibiotics, intravenous fluids, and ondansetron; admission) by physicians at 2 tertiary pediatric EDs for 4 common conditions (fever, head injury, respiratory illness, gastroenteritis). Resources used, ED length of stay (efficiency measure), and 72-hour return to ED (return rate [RR]) (balancing measure) were reported on scorecards with boxplots showing physicians their practice relative to peers. Quarterly scorecards were distributed for baseline (preintervention, July 2009-August 2010) and postintervention (September 2010-December 2011). Preintervention, postintervention, and trend analyses were performed.

RESULTS

In 51 450 patient visits (24 834 preintervention, 26 616 postintervention) seen by 96 physicians, we observed reduced postintervention use of abdominal and pelvic and head computed tomography scans, chest radiographs, intravenous antibiotics, and ondansetron (P < .01 for all). Hospital admissions decreased from 7.4% to 6.7% (P = .002), length of stay from 112 to 108 minutes (P < .001), and RR from 2.2% to 2.0%. Trends for use of laboratory tests and intravenous antibiotics showed significant reduction (P < .001 and P < .05, respectively); admission trends increased, and trends for use of computed tomography scans and plain abdominal radiographs showed no change.

CONCLUSIONS

Physician feedback on practice patterns relative to peers results in reduction in resource use for several common ED conditions without adversely affecting ED efficiency or quality of care.

Gastroenteritis Therapies in Developed Countries: Systematic Review and Meta-Analysis

Context

Gastroenteritis remains a leading cause of childhood morbidity.

Objective

Because prior reviews have focused on isolated symptoms and studies conducted in developing countries, this study focused on interventions commonly considered for use in developed countries. Intervention specific, patient-centered outcomes were selected.

Data Sources

MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, trial registries, grey literature, and scientific meetings.

Study Selection

Randomized controlled trials, conducted in developed countries, of children aged <18 years, with gastroenteritis, performed in emergency department or outpatient settings which evaluated oral rehydration therapy (ORT), antiemetics, probiotics or intravenous fluid administration rate.

Data Extraction

The study was conducted in accordance with the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA guidelines. Data were independently extracted by multiple investigators. Analyses employed random effects models.

Results

31 trials (4,444 patients) were included. ORT: Compared with intravenous rehydration, hospitalization (RR 0.80, 95%CI 0.24, 2.71) and emergency department return visits (RR 0.86, 95%CI 0.39, 1.89) were similar. Antiemetics: Fewer children administered an antiemetic required intravenous rehydration (RR 0.40, 95%CI 0.26, 0.60) While the data could not be meta-analyzed, three studies reported that ondansetron administration does increase the frequency of diarrhea. Probiotics: No studies reported on the primary outcome, three studies evaluated hospitalization within 7 days (RR 0.87, 95%CI 0.25, 2.98). Rehydration: No difference in length of stay was identified for rapid vs. standard intravenous or nasogastric rehydration. A single study found that 5% dextrose in normal saline reduced hospitalizations compared with normal saline alone (RR 0.70, 95% CI 0.53, 0.92).

Conclusions

There is a paucity of patient-centered outcome evidence to support many interventions. Since ORT is a low-cost, non-invasive intervention, it should continue to be used. Routine probiotic use cannot be endorsed at this time in outpatient children with gastroenteritis. Despite some evidence that ondansetron administration increases diarrhea frequency, emergency department use leads to reductions in intravenous rehydration and hospitalization. No benefits were associated with ondansetron use following emergency department discharge.

Association of clinical practice guidelines with emergency department management of febrile infants ≤56 days of age

BACKGROUND

Differences among febrile infant institutional clinical practice guidelines (CPGs) may contribute to practice variation and increased healthcare costs.

OBJECTIVE

Determine the association between pediatric emergency department (ED) CPGs and laboratory testing, hospitalization, ceftriaxone use, and costs in febrile infants.

DESIGN

Retrospective cross-sectional study in 2013.

SETTING

Thirty-three hospitals in the Pediatric Health Information System.

PATIENTS

Infants aged ≤56 days with a diagnosis of fever.

EXPOSURES

The presence and content of ED-based febrile infant CPGs assessed by electronic survey.

MEASUREMENTS

Using generalized estimating equations, we evaluated the association between CPG recommendations and rates of urine, blood, cerebrospinal fluid (CSF) testing, hospitalization, and ceftriaxone use at ED discharge in 2 age groups: ≤28 days and 29 to 56 days. We also assessed CPG impact on healthcare costs.

RESULTS

We included 9377 ED visits; 21 of 33 EDs (63.6%) had a CPG. For neonates ≤28 days, CPG recommendations did not vary and were not associated with differences in testing, hospitalization, or costs. Among infants 29 to 56 days, CPG recommendations for CSF testing and ceftriaxone use varied. CSF testing occurred less often at EDs with CPGs recommending limited testing compared to hospitals without CPGs (adjusted odds ratio: 0.5, 95% confidence interval: 0.3-0.8). Ceftriaxone use at ED discharge varied significantly based on CPG recommendations. Costs were higher for admitted and discharged infants 29 to 56 days old at hospitals with CPGs.

CONCLUSIONS

CPG recommendations for febrile infants 29 to 56 days old vary across institutions for CSF testing and ceftriaxone use, correlating with observed practice variation. CPGs were not associated with lower healthcare costs.

Emergency department ondansetron use in children with type 1 diabetes mellitus and vomiting

OBJECTIVE

To assess the hypothesis that ondansetron administration to children with type 1 diabetes mellitus (T1DM) presenting for emergency department (ED) care with intercurrent illness and vomiting improves clinical outcomes by reducing hospitalization rates (primary), length of ED stay, intravenous fluid (IVF) administration, and revisits (secondary outcomes).

STUDY DESIGN

We conducted a single-center, 10-year retrospective cohort study of 345 ED encounters of children aged 6 months-8 years with T1DM and vomiting. We compared outcomes among children receiving and not receiving ondansetron. To avoid selection bias related to ondansetron administration, we also investigated outcomes by conducting comparisons by ondansetron usage periods (ie, low [2002-2004] vs high [2009-2011]).

RESULTS

Ondansetron usage increased from 0% to 67% of ED encounters between 2002 and 2011. Admission rates were similar among those administered [54% (58/107)] and not administered ondansetron [55% (131/238)]. Length of stay was longer in children receiving ondansetron (409 vs 315 minutes; P = .03). IVF administration (77% vs 77%) and revisits (5.6% vs 5.9%) were similar. Ondansetron administration was not associated with reduced admission in logistic regression modeling. Admission rate (62%; 56/91 vs 49%; 57/111) (-13%, 95% CI -23%, 3%), length of stay (395 vs 327 minutes [IQR 164 501]; P < .001), and IVF administration decreased (84% [77/91] to 70% [78/111]; P = .02] when comparing low and high ondansetron usage periods.

CONCLUSIONS

Ondansetron administration was not independently associated with lower admission rates. Over time, along with increasing ondansetron use, there have been reductions in admissions, length of stay, and IVF administration in children with T1DM.

Real-time web-based assessment of total population risk of future emergency department utilization: statewide prospective active case finding study

Background

An easily accessible real-time Web-based utility to assess patient risks of future emergency department (ED) visits can help the health care provider guide the allocation of resources to better manage higher-risk patient populations and thereby reduce unnecessary use of EDs.

Objective

Our main objective was to develop a Health Information Exchange-based, next 6-month ED risk surveillance system in the state of Maine.

Methods

Data on electronic medical record (EMR) encounters integrated by HealthInfoNet (HIN), Maine’s Health Information Exchange, were used to develop the Web-based surveillance system for a population ED future 6-month risk prediction. To model, a retrospective cohort of 829,641 patients with comprehensive clinical histories from January 1 to December 31, 2012 was used for training and then tested with a prospective cohort of 875,979 patients from July 1, 2012, to June 30, 2013.

Results

The multivariate statistical analysis identified 101 variables predictive of future defined 6-month risk of ED visit: 4 age groups, history of 8 different encounter types, history of 17 primary and 8 secondary diagnoses, 8 specific chronic diseases, 28 laboratory test results, history of 3 radiographic tests, and history of 25 outpatient prescription medications. The c-statistics for the retrospective and prospective cohorts were 0.739 and 0.732 respectively. Integration of our method into the HIN secure statewide data system in real time prospectively validated its performance. Cluster analysis in both the retrospective and prospective analyses revealed discrete subpopulations of high-risk patients, grouped around multiple “anchoring” demographics and chronic conditions. With the Web-based population risk-monitoring enterprise dashboards, the effectiveness of the active case finding algorithm has been validated by clinicians and caregivers in Maine.

Conclusions

The active case finding model and associated real-time Web-based app were designed to track the evolving nature of total population risk, in a longitudinal manner, for ED visits across all payers, all diseases, and all age groups. Therefore, providers can implement targeted care management strategies to the patient subgroups with similar patterns of clinical histories, driving the delivery of more efficient and effective health care interventions. To the best of our knowledge, this prospectively validated EMR-based, Web-based tool is the first one to allow real-time total population risk assessment for statewide ED visits.

Ondansetron and probiotics in the management of pediatric acute gastroenteritis in developed countries

PURPOSE OF REVIEW

Acute gastroenteritis (AGE) is a common and impactful disease, typically managed with supportive care. There is considerable interest in the role of adjunctive therapies, particularly ondansetron and probiotics in improving AGE outcomes. The purpose of this review is to present the latest evidence regarding the use of these agents in children with AGE in developed countries.

RECENT FINDINGS

Single-dose oral ondansetron is effective and safe in reducing hospital admissions and the use of intravenous rehydration in children with AGE in emergency-department-based trials. Ondansetron use has increased significantly; however, 'real-world' studies of effectiveness have documented less impressive clinical impacts. Similarly, probiotic consumption is growing rapidly. Although several strains appear to reduce the duration of diarrhea in hospitalized children, current data are insufficient to support the routine use of probiotics in outpatient pediatric AGE.

SUMMARY

Ondansetron and probiotics may improve patient outcomes in pediatric AGE. Appropriate strategies are needed to optimally integrate oral ondansetron into clinical practice to maximize its potential benefits. Although probiotics remain a promising option, there are challenges in generalizing the data available to patients presenting for outpatient care. Large randomized controlled trials are needed to definitively guide the clinical use of probiotics in outpatients in developed countries.

Variability in inpatient management of children hospitalized with bronchiolitis

OBJECTIVE

To determine the variability between hospitals in diagnostic testing and management interventions for children with bronchiolitis admitted to inpatient wards and identify its association with patient characteristics.

METHODS

A prospective, multicenter (16 hospitals), multiyear (2007-2010) observational study of children (age <2 years) hospitalized with bronchiolitis. Outcomes included variability in diagnostic testing (complete blood count, chest radiographs) and medications or interventions (bronchodilator, systemic corticosteroid, antibiotic, IV placement) by hospital. A modified Respiratory Distress Severity Score was utilized to assess severity of illness. For all outcomes, intraclass correlation coefficient (ICC) was calculated from a model to estimate the random effects of hospital without added covariates and compared to ICCs from a second model that adjusted for demographic and clinical patient characteristics. A second unadjusted and adjusted model was created for age ≥ 2 months.

RESULTS

Of 2207 subjects, 1715 were identified as admitted to inpatient wards. We observed wide variations in the proportion of patients who received diagnostic testing (complete blood count 21-75%, chest radiograph 36-85%) and medications/interventions (bronchodilators 19-91%, systemic corticosteroids 8-44%, antibiotics 17-43%, IV placement 38-93%). Adjusting for demographic and clinical patient characteristics did not materially affect the proportion of variability attributable to hospitals (differences in ICCs with and without model adjustment <4%).

CONCLUSIONS

Wide variations in diagnostic test utilization and management interventions seen among children with bronchiolitis treated on the inpatient wards at 16 US hospitals were not attributable to demographic or clinical patient characteristics. These results further support efforts to standardize care for bronchiolitis through active quality improvement strategies.

Risk prediction of emergency department revisit 30 days post discharge: a prospective study

BACKGROUND

Among patients who are discharged from the Emergency Department (ED), about 3% return within 30 days. Revisits can be related to the nature of the disease, medical errors, and/or inadequate diagnoses and treatment during their initial ED visit. Identification of high-risk patient population can help device new strategies for improved ED care with reduced ED utilization.

METHODS AND FINDINGS

A decision tree based model with discriminant Electronic Medical Record (EMR) features was developed and validated, estimating patient ED 30 day revisit risk. A retrospective cohort of 293,461 ED encounters from HealthInfoNet (HIN), Maine's Health Information Exchange (HIE), between January 1, 2012 and December 31, 2012, was assembled with the associated patients' demographic information and one-year clinical histories before the discharge date as the inputs. To validate, a prospective cohort of 193,886 encounters between January 1, 2013 and June 30, 2013 was constructed. The c-statistics for the retrospective and prospective predictions were 0.710 and 0.704 respectively. Clinical resource utilization, including ED use, was analyzed as a function of the ED risk score. Cluster analysis of high-risk patients identified discrete sub-populations with distinctive demographic, clinical and resource utilization patterns.

CONCLUSIONS

Our ED 30-day revisit model was prospectively validated on the Maine State HIN secure statewide data system. Future integration of our ED predictive analytics into the ED care work flow may lead to increased opportunities for targeted care intervention to reduce ED resource burden and overall healthcare expense, and improve outcomes.

Implementing a guideline to improve management of syncope in the emergency department

BACKGROUND AND OBJECTIVES

Thirty-five percent of children experience syncope at least once. Although the etiology of pediatric syncope is usually benign, many children undergo low-yield diagnostic testing. We conducted a quality improvement intervention to reduce the rates of low-yield diagnostic testing for children presenting to an emergency department (ED) with syncope or presyncope.

METHODS

Children 8 to 22 years old presenting to a tertiary care pediatric ED with syncope or presyncope were included. We excluded children who were ill-appearing, had previously diagnosed cardiac or neurologic disease, ingestion, or trauma. We measured diagnostic testing rates among children presenting from July 2010 through October 2012, during which time we implemented a quality improvement intervention. Patient follow-up was performed 2 months after the ED visit to ascertain subsequent diagnostic testing and medical care.

RESULTS

A total of 349 patients were included. We observed a reduction in the rates of low-yield diagnostic testing after our quality improvement intervention: complete blood count testing decreased from 36% (95% confidence interval 29% to 43%) to 16% (12% to 22%) and electrolyte testing from 29% (23% to 36%) to 12% (8% to 17%). Performance of recommended testing increased, such as electrocardiograms and pregnancy testing in postpubertal girls. Despite a reduction in diagnostic testing among children with syncope, patients were not more likely to undergo subsequent diagnostic testing or seek further medical care following their ED visit.

CONCLUSIONS

Implementation of a quality improvement intervention for the ED evaluation of pediatric syncope was associated with reduced low-yield diagnostic testing, and was not associated with subsequent testing or medical care.

Characteristics of recurrent utilization in pediatric emergency departments

BACKGROUND AND OBJECTIVE

Nationally, frequent utilizers of emergency departments (EDs) are targeted for quality improvement initiatives. The objective was to compare the characteristics and ED health services of children by their ED visit frequency.

METHODS

A retrospective study in 1,896,547 children aged 0 to 18 years with 3,263,330 visits to 37 EDs in 2011. The number of ED visits per child within 365 days of their first visit was counted. Patient characteristics (age, chronic condition) and ED care (medications, testing [laboratory and radiographic], and hospital admission) were assessed. We evaluated the relationship between patient characteristics and ED health services received with multivariable regression.

RESULTS

Children with ≥4 ED visits (8%) accounted for 24% of all visits and 31% ($1.4 billion) of all costs. As visit frequency increased from 1 to ≥4, the percentage of children aged <1 year increased (12.1% to 33.2%) and the percentage of children without a chronic condition decreased (81.9% to 45.6%) (P < .001 for both). Children with ≥4 ED visits had a higher percentage of visits without medication administration (aside from acetaminophen or ibuprofen), testing, or hospital admission when compared with children with 1 visit (35.4% vs 29.0%; P < .001). Children with ≥4 ED visits who were aged <1 year (odds ratio: 3.8; 95% confidence interval: 3.7-3.9) and who were without a chronic condition (odds ratio: 3.1; 95% confidence interval: 3.0-3.1) had the highest likelihood of experiencing this type of visit.

CONCLUSIONS

With a disproportionate share of pediatric ED cost and utilization, frequent utilizers, especially infants without a chronic condition, are the least likely to need medications, testing, and hospital admission.

Variation in care of the febrile young infant <90 days in US pediatric emergency departments

BACKGROUND AND OBJECTIVES

Variation in patient care or outcomes may indicate an opportunity to improve quality of care. We evaluated the variation in testing, treatment, hospitalization rates, and outcomes of febrile young infants in US pediatric emergency departments (EDs).

METHODS

Retrospective cohort study of infants <90 days of age with a diagnosis code of fever who were evaluated in 1 of 37 pediatric EDs between July 1, 2011 and June 30, 2013. We assessed patient- and hospital-level variation in testing, treatment, and disposition for patients in 3 distinct age groups: ≤28, 29 to 56, and 57 to 89 days. We also compared interhospital variation for 3-day revisits and revisits resulting in hospitalization.

RESULTS

We identified 35,070 ED visits that met inclusion criteria. The proportion of patients who underwent comprehensive evaluation, defined as urine, serum, and cerebrospinal fluid testing, decreased with increasing patient age: 72.0% (95% confidence interval [CI], 71.0-73.0) of neonates ≤28 days, 49.0% (95% CI, 48.2-49.8) of infants 29 to 56 days, and 13.1% (95% CI, 12.5-13.6) of infants 57 to 89 days. Significant interhospital variation was demonstrated in testing, treatment, and hospitalization rates overall and across all 3 age groups, with little interhospital variation in outcomes. Hospitalization rate in the overall cohort did not correlate with 3-day revisits (R(2) = 0.10, P = .06) or revisits resulting in hospitalization (R(2) = 0.08, P = .09).

CONCLUSIONS

Substantial patient- and hospital-level variation was observed in the ED management of the febrile young infant, without concomitant differences in outcomes. Strategies to understand and address the modifiable sources of variation are needed.

Variation in emergency department admission rates in US children's hospitals

OBJECTIVE

To measure the hospital-level variation in admission rates for children receiving treatment of common pediatric illnesses across emergency departments (EDs) in US children's hospitals.

METHODS

We performed a multi-center cross sectional study of children presenting to the EDs of 35 pediatric tertiary-care hospitals participating in the Pediatric Health Information System (PHIS). Admission rates were calculated for visits occurring between January 1, 2009, and December 31, 2012, associated with 1 of 7 common conditions, and corrected to adjust for hospital-level severity of illness. Conditions were selected systematically based on frequency of visits and admission rates.

RESULTS

A total of 1288706 ED encounters (13.8% of all encounters) were associated with 1 of the 7 conditions of interest. After adjusting for hospital-level severity, the greatest variation in admission rates was observed for concussion (range 5%-72%), followed by pneumonia (19%-69%), and bronchiolitis (19%-65%). The least variation was found among patients presenting with seizures (7%-37%) and kidney and urinary tract infections (6%-37%). Although variability existed in disease-specific admission rates, certain hospitals had consistently higher, and others consistently lower, admission rates.

CONCLUSIONS

We observed greater than threefold variation in severity-adjusted admission rates for common pediatric conditions across US children's hospitals. Although local practices and hospital-level factors may partly explain this variation, our findings highlight the need for greater focus on the standardization of decisions regarding admission.

Readmissions among children previously hospitalized with pneumonia

BACKGROUND AND OBJECTIVES

Pneumonia is a leading cause of hospitalization and readmission in children. Understanding the patient characteristics associated with pneumonia readmissions is necessary to inform interventions to reduce avoidable hospitalizations and related costs. The objective of this study was to characterize readmission rates, and identify factors and costs associated with readmission among children previously hospitalized with pneumonia.

METHODS

Retrospective cohort study of children hospitalized with pneumonia at the 43 hospitals included in the Pediatric Health Information System between January 1, 2008, and December 31, 2011. The primary outcome was all-cause readmission within 30 days after hospital discharge, and the secondary outcome was pneumonia-specific readmission. We used multivariable regression models to identify patient and hospital characteristics and costs associated with readmission.

RESULTS

A total of 82 566 children were hospitalized with pneumonia (median age, 3 years; interquartile range 1-7). Thirty-day all-cause and pneumonia-specific readmission rates were 7.7% and 3.1%, respectively. Readmission rates were higher among children <1 year of age, as well as in patients with previous hospitalizations, longer index hospitalizations, and complicated pneumonia. Children with chronic medical conditions were more likely to experience all-cause (odds ratio 3.0; 95% confidence interval 2.8-3.2) and pneumonia-specific readmission (odds ratio 1.8; 95% confidence interval 1.7-2.0) compared with children without chronic medical conditions. The median cost of a readmission ($11 344) was higher than that of an index admission ($4495; P = .01). Readmissions occurred in 8% of pneumonia hospitalizations but accounted for 16.3% of total costs for all pneumonia hospitalizations.

CONCLUSIONS

Readmissions are common after hospitalization for pneumonia, especially among young children and those with chronic medical conditions, and are associated with substantial costs.