The impact of race and ethnicity on care in the pediatric emergency department

Management of Psychiatric Emergencies Among Migrant Youth in Institutional and Community Settings

Migrant youth commonly access mental health care for the first time during emergencies, rather than through ambulatory means. Suicidal behaviors may occur more often among migrants than nonmigrant youth, and they may suffer from post-traumatic stress, depression, anxiety, and display disruptive behaviors more frequently than their nonmigrant counterparts. Brief emergency interventions include safety planning, psychoeducation, parent training on communication and establishing routines, and behavioral therapies like activity scheduling and sleep hygiene.

Shades of care: Understanding the needs of racially and ethnically diverse paediatric patients, their families, and health care providers in North America

While race and ethnicity have been acknowledged as determinants of health, there remain gaps regarding their effects on experiences of paediatric care. This scoping review examines empirical literature regarding the state and experience of paediatric care provided to racially and ethnically diverse families in North America. We seek to clarify the needs of care administrators and recipients, as well as to conceptualize what paediatric care must look like to enable equitable practices and optimal health outcomes. Utilizing Arksey and O'Malley's framework, we reviewed literature published between 2005 and 2020, most of which was written within an American context. The literature reviewed featured quantitative, qualitative and mixed methods studies. Paediatric care administrators and recipients collectively identified the following as domains requiring an increased focus: (1) knowledge (awareness or training), (2) alignment of views and values, (3) resources and (4) communication. Findings suggest overall that despite there being merit in the cultural competency efforts underway, more patient-centric approaches are vital. This review concludes by encouraging the sustained development of cultural safety initiatives in paediatric care to ultimately promote patient comfort and provider-patient collaboration.

Do children evaluated for maltreatment have higher subsequent emergency department and inpatient care utilization compared to a general pediatric sample?

BACKGROUND

Child maltreatment leads to substantial adverse health outcomes, but little is known about acute health care utilization patterns after children are evaluated for a concern of maltreatment at a child abuse and neglect medical evaluation clinic.

OBJECTIVE

To quantify the association of having a child maltreatment evaluation with subsequent acute health care utilization among children from birth to age three.

PARTICIPANTS AND SETTING

Children who received a maltreatment evaluation (N = 367) at a child abuse and neglect subspecialty clinic in an academic health system in the United States and the general pediatric population (N = 21,231).

METHODS

We conducted a retrospective cohort study that compared acute health care utilization over 18 months between the two samples using data from electronic health records. Outcomes were time to first emergency department (ED) visit or inpatient hospitalization, maltreatment-related ED use or inpatient hospitalization, and ED use or inpatient hospitalization for ambulatory care sensitive conditions (ACSCs). Multilevel survival analyses were performed.

RESULTS

Children who received a maltreatment evaluation had an increased hazard for a subsequent ED visit or inpatient hospitalization (hazard ratio [HR]: 1.3, 95 % confidence interval [CI]: 1.1, 1.5) and a maltreatment-related visit (HR: 4.4, 95 % CI: 2.3, 8.2) relative to the general pediatric population. A maltreatment evaluation was not associated with a higher hazard of health care use for ACSCs (HR: 1.0, 95 % CI: 0.7, 1.3).

CONCLUSION

This work can inform targeted anticipatory guidance to aid high-risk families in preventing future harm or minimizing complications from previous maltreatment.

Emergency Department Visits and Hospitalizations After Pediatric Tracheostomy

OBJECTIVE

To determine factors associated with frequent emergency department (ED) visits and hospitalizations after pediatric tracheostomy.

METHODS

A prospective cohort of children (<18 years) with a tracheostomy placed at a tertiary children's hospital between 2015 and 2019 were followed for 24 months after index discharge. ED visits and hospitalizations were recorded to identify risk factors for frequent utilization (≥4 visits).

RESULTS

A total of 239 children required 1285 total visits to the ED or hospital after index discharge with 112 children (47%) having ≥4 visits. Respiratory-related illness was the most common reason (N = 699, 54%) followed by gastrostomy tube issues (N = 119, 9.3%). Frequent utilization was associated with Black race (OR: 2.01, 95% CI: 1.18-3.70, p = 0.01), mechanical ventilation (OR: 2.74, 95% CI: 1.35-5.59, p = 0.006), and Spanish language (OR: 3.86, 95% CI: 1.47-10.11, p = 0.006) on regression modeling. There were no predictors of visits for tracheostomy-related complications, which accounted for 4.8% of all encounters. A sub-analysis showed that Hispanic ethnicity and gestational age predicted visits for respiratory failure.

CONCLUSION

Frequent ED visits or hospitalizations are required for 47% of children in the first 2 years after tracheostomy placement. Ventilatory support, Black race, and Spanish language increase the likelihood of high utilization. Although tracheostomy-related visits are uncommon, strategies to anticipate and decrease respiratory-related admissions may have the most impact.

LEVEL OF EVIDENCE

3 Laryngoscope, 2022.

Child's Illness Representation Instrument: Testing Reliability & Factor Structure Study

BACKGROUND

Researchers have determined that illness representation, including identifying the illness, understanding the cause, and knowing the risk, may influence asthma symptom management.

PURPOSE

The purpose of study was to determine reliability and factor structure for child's version of illness representation.

METHODS

A Maximum Likelihood factor analysis was used to examine reliability and factor structure of the child version of illness representation (CIR) scale. The sample included teens ages 12 to 18 from United States (N=331) with asthma.

RESULTS

The reliability was 0.79. Eight factors loaded with the most percentage of variance.

CONCLUSIONS

The perceptions of teens on the health care provider's prescribing practices may shed light on medication adherence. More research is needed to examine CIRS function in a study on medication adherence.

Accidental Injuries in Preschoolers: Are We Missing an Opportunity for Early Assessment and Intervention?

OBJECTIVE

Children with attention-deficit/hyperactivity disorder (ADHD) are at risk for accidental injuries, but little is known about age-related changes in early childhood. We predicted that ADHD would be associated with greater frequency and volume of accidental injuries. We explored associations between ADHD and injury types and examined age-related changes within the preschool period.

METHODS

Retrospective chart review data of 21,520 preschool children with accidental injury visits within a large pediatric hospital network were examined. We compared children with ADHD (n = 524) and without ADHD (n = 20,996) on number of injury visits by age, total number of injury visits, injury volume, and injury type.

RESULTS

Children with ADHD averaged fewer injury visits at age 3 and 90% more visits at age 6. Children with ADHD had injury visits in more years during the 3-6 age. There were no differences in injury volumes. Among patients with an injury visit at age 3, children with ADHD had 6 times the probability of a subsequent visit at age 6. At age 3, children with ADHD were estimated to have 50% fewer injury visits than children without ADHD, but by age 6, children with ADHD had an estimated 74% more injury visits than children without ADHD. Risk for several injury types for children with ADHD exceeded that for patients without ADHD by at least 50%.

CONCLUSIONS

Early identification and treatment of preschool ADHD following accidental injury may prevent subsequent injuries. Clinical implications and future directions are discussed with emphasis on the maintenance of parental monitoring into the older preschool years.

The Impact of Racism on Child and Adolescent Health

The American Academy of Pediatrics is committed to addressing the factors that affect child and adolescent health with a focus on issues that may leave some children more vulnerable than others. Racism is a social determinant of health that has a profound impact on the health status of children, adolescents, emerging adults, and their families. Although progress has been made toward racial equality and equity, the evidence to support the continued negative impact of racism on health and well-being through implicit and explicit biases, institutional structures, and interpersonal relationships is clear. The objective of this policy statement is to provide an evidence-based document focused on the role of racism in child and adolescent development and health outcomes. By acknowledging the role of racism in child and adolescent health, pediatricians and other pediatric health professionals will be able to proactively engage in strategies to optimize clinical care, workforce development, professional education, systems engagement, and research in a manner designed to reduce the health effects of structural, personally mediated, and internalized racism and improve the health and well-being of all children, adolescents, emerging adults, and their families.

Pediatric Emergency Visits and Short-Term Changes in PM2.5 Concentrations in the U.S. State of Georgia

BACKGROUND

Associations between pediatric emergency department (ED) visits and ambient concentrations of particulate matter ≤ 2.5 μm in diameter (PM2.5) have been reported in previous studies, although few were performed in nonmetropolitan areas.

OBJECTIVE

We estimated associations between daily PM2.5 concentrations, using a two-stage model that included land use parameters and satellite aerosol optical depth measurements at 1-km resolution, and ED visits for six pediatric conditions in the U.S. state of Georgia by urbanicity classification.

METHODS

We obtained pediatric ED visits geocoded to residential ZIP codes for visits with nonmissing PM2.5 estimates and admission dates during 1 January 2002-30 June 2010 for 2- to 18-year-olds for asthma or wheeze (n = 189,816), and for 0- to 18-year-olds for bronchitis (n = 76,243), chronic sinusitis (n = 15,745), otitis media (n = 237,833), pneumonia (n = 52,946), and upper respiratory infections (n = 414,556). Daily ZIP code-level estimates of 24-hr average PM2.5 were calculated by averaging concentrations within ZIP code boundaries. We used time-stratified case-crossover models stratified on ZIP code, year, and month to estimate odds ratios (ORs) between ED visits and same-day and previous-day PM2.5 concentrations at the ZIP code level, and we investigated effect modification by county-level urbanicity.

RESULTS

A 10-μg/m3 increase in same-day PM2.5 concentrations was associated with ED visits for asthma or wheeze (OR = 1.013; 95% CI: 1.003, 1.023) and upper respiratory infections (OR = 1.015; 95% CI: 1.008, 1.022); associations with previous-day PM2.5 concentrations were lower. Differences in the association estimates across levels of urbanicity were not statistically significant.

CONCLUSION

Pediatric ED visits for asthma or wheeze and for upper respiratory infections were associated with PM2.5 concentrations in Georgia.

CITATION

Strickland MJ, Hao H, Hu X, Chang HH, Darrow LA, Liu Y. 2016. Pediatric emergency visits and short-term changes in PM2.5 concentrations in the U.S. state of Georgia. Environ Health Perspect 124:690-696; http://dx.doi.org/10.1289/ehp.1509856.

Pediatric Use of Emergency Medical Services: The Role of Chronic Illnesses and Behavioral Health Problems

OBJECTIVE

The increasing use of prehospital emergency medical services (EMS) and its contribution to rising emergency department use and healthcare costs point to the need for better understanding factors associated with EMS use to inform preventive interventions. Understanding patient factors associated with pediatric use of EMS will inform pediatric-specific intervention. We examined pediatric patient demographic and health factors associated with one-time and repeat use of EMS.

METHODS

We reviewed data from Baltimore City Fire Department EMS patient records over a 23-month period (2008-10) for patients under 21 years of age (n = 24,760). Repeat use was defined as involvement in more than one EMS incident during the observation period. Analyses compared demographics of EMS users to the city population and demographics and health problems of repeat and one-time EMS users. Health comparisons were conducted at the patient and incident levels of analysis.

RESULTS

Repeat users (n = 1,931) accounted for 9.0% of pediatric users and 20.8% of pediatric incidents, and were over-represented among the 18-20 year age group and among females. While trauma accounted for approximately one-quarter of incidents, repeat versus one-time users had a lower proportion of trauma-related incidents (7.2% vs. 26.7%) and higher proportion of medical-related incidents (92.6% vs. 71.4%), including higher proportions of incidents related to asthma, seizures, and obstetric/gynecologic issues. In patient-level analysis, based on provider or patient reports, greater proportions of repeat compared to one-time users had asthma, behavioral health problems (mental, conduct and substance use problems), seizures, and diabetes.

CONCLUSIONS

Chronic somatic conditions and behavioral health problems appear to contribute to a large proportion of the repeat pediatric use of this EMS system. Interventions may be needed to engage repeat users in primary care and behavioral health services, to train EMS providers on the recognition and management of behavioral health emergencies, and to improve family care and self-management of pediatric asthma and other chronic conditions.

Initiating an online asthma management program in urban emergency departments: the recruitment experience

BACKGROUND

The emergency department could represent a means of identifying patients with asthma who could benefit from asthma interventions.

OBJECTIVE

To assess the initiation of a Web-based tailored asthma intervention in the emergency department of 2 urban tertiary care hospitals.

METHODS

In addition to awareness strategies for emergency department staff (eg, attending nursing huddles, division meetings, etc), recruitment experiences are described for 2 strategies: (1) recruitment during an emergency department visit for acute asthma and (2) recruitment from patient listings (mail or telephone). Patient enrollment was defined as baseline completion, randomization, and completion of the first of 4 online sessions.

RESULTS

Of 499 eligible patients 13 to 19 years old visiting the emergency department for asthma during the study period, 313 (63%) were contacted in the emergency department (n = 65) or by mail or telephone (n = 350). Of these, 121 (38.6%) were randomized. Mean age of the study sample was 15.4 years and 88.4% were African American. Refusal rates for emergency department recruitment and mail or telephone were 18.5% (12 of 65) and 16.6% (58 of 350), respectively. On average, emergency department enrollment took 44 to 67 minutes, including downtime. When surveyed, emergency department providers were more positive about awareness activities and emergency department recruitment than were research staff.

CONCLUSION

Emergency department recruitment was feasible but labor intensive. Refusal rates were similar for the 2 strategies. Targeting patients with acute asthma in the emergency department is one way of connecting with youth at risk of future acute events.

Experiences, Functioning and Needs of Low-Income African American Mothers of Children With Asthma

The purpose of this proposed study was to explore experiences, needs and functioning of low-income, African American caregivers of children with asthma in order to better understand symptom management.

METHOD

A qualitative, descriptive design was used. A purposive sampling technique was used to screen 32 caregivers of children with asthma, and 15 caregivers agreed to participate.

RESULTS

Three main themes were identified: managing the symptoms; cultural beliefs and values; and culturally competent health care provider.

CONCLUSION

For the caregivers culture disparity is not just about access to health services but instead the healthcare providers' understanding of the complexity of symptoms management.

Regional and socioeconomic disparities in emergency department use of radiographic imaging for acute pediatric sinusitis

BACKGROUND

Acute pediatric sinusitis (APS) is a common complication of pediatric upper respiratory tract infections. Children with all degrees of APS severity may present to emergency departments (EDs) for evaluation and management. This study was designed to analyze the use of imaging in APS presenting to U.S. EDs.

METHODS

A cross-sectional analysis of the 2008 National Emergency Department Sample database was performed. One hundred one thousand six hundred sixty children, aged ≤18 years, assigned at least one ICD9 code for APS were identified. Current procedural terminology codes for sinus plain film radiographs, computed tomography (CT), and magnetic resonance imaging identified children who underwent sinus imaging. Association of performance of sinus imaging was sought with multiple predictor variables including clinicodemographic and hospital characteristics.

RESULTS

The use of any imaging was associated with older age (odds ratio [OR] = 1.07; p < 0.001), male gender (OR = 1.57; p < 0.001), and diagnosis of chronic rhinosinusitis (OR = 2.46; p < 0.001). Imaging was more common in metropolitan teaching (OR = 1.40;0 p < 0.001) and nonteaching (OR = 5.64; p < 0.001) hospitals. Markers of higher socioeconomic status--private health insurance (OR = 1.37; p < 0.001) and higher income level (OR = 1.96; p < 0.001)--were associated with greater use of imaging, especially CT scans.

CONCLUSION

The use of ED imaging in APS is appropriately associated with factors known to be associated with APS complications. However, additional disparities with respect to regional and socioeconomic factors exist. Interventions to eliminate these health care disparities in use of imaging resources may lead to quality improvement in care and outcomes for APS.

Latino caregiver experiences with asthma health communication

In this article, we analyze qualitative data from a purposeful sample of limited English proficiency (LEP) asthma health caregivers. We used ethnically concordant, semistructured, in-depth Spanish-language interviews and a follow-up focus group to explore issues related to communication during pediatric asthma encounters in medical settings. Inductive coding of Spanish transcripts by a bilingual research team was performed until thematic saturation was reached. Several key findings emerged. LEP caregivers encountered significant asthma burdens related to emotional stress, observed physical changes, and communication barriers. Language-discordant communication and the use of ad hoc interpreters were common. This finding is complex, and was influenced by perceptions of interpreter availability, delays in care, feelings of mistrust toward others, and individual emotional responses. Language-concordant education and suitable action plans were valued and desired. We discuss a revealing depiction of the LEP caregiver experience with asthma health communication and recommend areas for further inquiry.

Association of positive responses to suicide screening questions with hospital admission and repeated emergency department visits in children and adolescents

OBJECTIVES

Although validated suicide screening tools exist for use among children and adolescents presenting to emergency departments (EDs), the associations between screening positive for suicide risk and immediate psychiatric hospital admission or subsequent ED use, stratified by age, have not been examined.

METHODS

This is a retrospective cohort study of a consecutive case series of patients aged 8 to 18 years presenting with psychiatric chief complaints during a 9-month period to a single urban tertiary care pediatric ED. Eligible patients were administered a subset of questions from the Risk of Suicide Questionnaire. Outcomes included the odds of psychiatric hospitalization at the index visit and repeated ED visits for psychiatric complaints within the following year, stratified by age.

RESULTS

Of the 568 patients presenting during the study period, responses to suicide screening questions were available for 442 patients (78%). A total of 159 (36%) of 442 were hospitalized and 130 (29%) of 442 had 1 or more ED visits within the following year. The proportion of patients providing positive responses to 1 or more suicide screening questions did not differ between patients aged 8 to 12 years and those aged 13 to 18 years (77/154 [50%] vs 137/288 [48%], P = 0.63). A positive response to 1 or more of the questions was significantly associated with increased odds of psychiatric hospitalization in the older age group [adjusted odds ratio, 3.82; 95% confidence interval, 2.24-6.54) and with repeated visits to the ED in the younger age group (adjusted odds ratio, 3.55 95% confidence interval, 1.68-7.50).

CONCLUSIONS

Positive responses to suicide screening questions were associated with acute psychiatric hospitalization and repeated ED visits. Suicide screening in a pediatric ED may identify children and adolescents with increased need of psychiatric resources.

The impact of race on outcomes following emergency surgery: an American College of Surgeons National Surgical Quality Improvement Program assessment

BACKGROUND

Despite significant evolutions in health care, outcome discrepancies exist among demographic cohorts. We sought to determine the impact of race on emergency surgery outcomes.

METHODS

This is a retrospective review of the American College of Surgeons National Surgical Quality Improvement Program database (2005 through 2009) for all patients aged ≥16 years undergoing emergency abdominal surgery. Primary outcomes included morbidity and mortality.

RESULTS

We identified 75,280 patients (mean age 48.2 ± 19.9 years, 51.7% female; 79% white, 9.9% black, 5.0% Hispanic, 3.7% Asian, 1.3% American Indian or Alaskan, .2% Pacific Islander). Annual rates of emergency operations ranged from 7.3% to 8.5% (P = .22). The overall complication (18.6%) and mortality rate (4.6%) was highest in the black population (24.3%, 5.3%) followed by whites (18.7%, 4.6%), with the lowest rate in Hispanic (11.7%, 1.8%) and Pacific Islander populations (10.2%, 1.8%; P < .001). Compared with whites, blacks had a 1.25-fold (1.17 to 1.34; P < .001) increased risk of complications, but similar mortality (P = .168). When combining minorities, overall complications were 1.059-fold (1.004 to 1.12; P = .034) higher, however, mortality was reduced 1.7-fold (1.07 to 1.34; P = .001).

CONCLUSIONS

Following emergency abdominal surgery, minority race is independently associated with increased complications and reduced mortality.

Evaluation of a web-based asthma management intervention program for urban teenagers: reaching the hard to reach

PURPOSE

Asthma interventions targeting urban adolescents are rare, despite a great need. Motivating adolescents to achieve better self-management of asthma is challenging, and the literature suggests that certain subgroups are more resistant than others. We conducted a school-based, randomized controlled trial (RCT) to evaluate Puff City, a Web-based, tailored asthma intervention, which included a referral coordinator, and incorporated theory-based strategies to target urban teens with characteristics previously found to be associated with lack of behavior change.

METHODS

To identify eligible teens, we administered questionnaires on asthma diagnoses and symptoms to ninth through 12th graders of participating schools during a scheduled English class. We randomized eligible, consenting students to Puff City (treatment) or generic asthma education (control).

RESULTS

We randomized 422 students (98% African-American, mean age = 15.6 years). At 12-month follow-up, adjusted odds ratios (aORs) (95% confidence intervals) indicated intervention benefit for treatment teens for symptom-days and restricted activity days (analyzed as categorical variables) as aOR = .49 (.24-.79), p = .006 and .53 (.32-.86), p = .010, respectively. Among teens meeting baseline criteria for rebelliousness, treatment teens reported fewer symptom-days, symptom-nights, school absences, and restricted activity days: aOR = .30 (.11-.80), .29 (.14-.64), .40 (.20-.78), and .23 (.10-.55); all p < .05. Among teens reporting low perceived emotional support, treatment students reported only fewer symptom-days than controls: aOR = .23 (.06-.88), p = .031. We did not observe statistically significant differences in medical care use.

CONCLUSIONS

Results suggest that a theory-based, tailored approach, with a referral coordinator, can improve asthma management in urban teens. Puff City represents a viable strategy for disseminating an effective intervention to high-risk and hard-to-reach populations.

A research agenda to assure equity during periods of emergency department crowding

The effect of emergency department (ED) crowding on equitable care is the least studied of the domains of quality as defined by the Institute of Medicine (IOM). Inequities in access and treatment throughout the health care system are well documented in all fields of medicine. While there is little evidence demonstrating that inequity is worsened by crowding, theory and evidence from social science disciplines, as well as known barriers to care for vulnerable populations, would suggest that crowding will worsen inequities. To design successful interventions, however, it is important to first understand how crowding can result in disparities and base interventions on these mechanisms. A research agenda is proposed to understand mechanisms that may threaten equity during periods of crowding and design and test potential interventions that may ensure the equitable aspect of quality of care.