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

Difficult Intravenous Access Requiring Ultrasound in the Emergency Department: Associations With Delays in Care and Areas for Quality Improvement

Background Patients with difficult intravenous access (DIVA) requiring ultrasound-guided intravenous (USGIV) access have been associated with delays in treatment, imaging, and disposition in academic emergency department (ED) patient populations. Our objective in this study was to characterize differences in time to intravenous access, imaging, and disposition between patients with DIVA versus those without DIVA requiring USGIV access in a community ED while also assessing for DIVA-associated comorbidities. Methods A cross-sectional, observational analysis was performed on admitted ED patients evaluated from September 2 to September 31, 2022, at a community ED. Patients with DIVA were defined as patients with two failed attempts at traditional intravenous placement. These patients require USGIV placement per institutional protocol. Patients younger than 18 years of age, trauma admissions, repeated visits from the same patient, patients with missing data, and direct hospital admissions were excluded. Continuous variables were recorded with medians and included ED throughput measures of time to vascular access, contrast CT imaging, and disposition. Differences in median times between DIVA patients versus non-DIVA patients were assessed with the Mann-Whitney U-test. Categorical data involving comorbidities were reported as percentages, and differences in proportions between DIVA versus non-DIVA patients were assessed via chi-square tests. Multivariate logistic regression analysis evaluated for correlations between DIVA and times to access, contrast CT imaging, disposition, and significant covariates while adjusting for demographic information. Results A total of 1250 patients were included in this investigation (5.8% associated with DIVA requiring USGIV access). The median age of all subjects was 69 (interquartile range = 58, 79) with no significant difference between the DIVA and non-DIVA groups. Patients with DIVA were more likely to be female in comparison to patients without DIVA (65.3% and 51.2%, respectively, p < 0.05). Patients with a history of end-stage renal disease (ESRD) (p < 0.001), intravenous drug use (IVDU) (p < 0.001), and venous thromboembolism (p < 0.05) had statistically significant associations with DIVA. On regression analysis, patients with DIVA were more likely to have a history of ESRD with an odds ratio (OR) of 3.56 (95% confidence interval (CI): 1.62-7.81) and a history of IVDU with an OR of 14.29 (95% CI: 5.17-39.54). Patients with DIVA were associated with statistically significant greater median times to vascular access, contrast CT imaging, and disposition (p < 0.001 for time to access and disposition and p < 0.01 for time to contrast CT imaging). Conclusion In this study, DIVA cases requiring USGIV access were positively associated with significantly longer times to access, contrast CT imaging, and disposition compared to patients without DIVA at our community ED. Comorbidities such as IVDU and ESRD had statistically significant associations with DIVA requiring USGIV access.

The Importance of Subspecialty Pediatricians to the Health and Wellbeing of the Nation's Children

Through this review of published literature, it is clear that children benefit in measurable ways when they receive care from trained pediatric subspecialists. The improved outcomes provided by pediatric subspecialists supports the care provided in the patient's pediatric medical home and emphasizes the importance of care coordination between all components of the pediatric workforce. The AAP highlights this in a recent policy statement by stating the care provided by pediatric clinicians "encompasses diagnosis and treatment of acute and chronic health disorders; management of serious and life-threatening illnesses; and when appropriate, referral of patients with more complex conditions for medical subspecialty or surgical specialty care" Explicit in this statement is the emphasis on the role of complex care coordination between pediatric specialist and primary care pediatricians and that collaboration and guidance by the pediatrician is central to providing optimal care of patients. ⁶⁵ Improving health outcomes early in life is an important public health strategy for modifying the complications from childhood chronic disease and highlights the role of pediatricians in mitigating the long-term consequences of antecedents of adult disease. ⁶⁶ The recent announcement of the National Academies of Science, Engineering, and Medicine (NASEM)'s plan for a Consensus Study on The Pediatric Subspecialty Workforce and Its Impact on Child Health and Well-being is a related and exciting development, on a national scale. ⁶⁷ In response to shortages and geographic maldistributions of pediatric subspecialists, the NASEM committee intends to assess the impact of current pediatric clinical workforce trends on child health and well-being, in order to develop informed strategies to ensure an adequate, high-quality pediatric workforce, with a robust research portfolio that informs those recommendations. While this large, national initiative will surely lead to a better understanding of and strategies to implement across the pediatric subspecialty workforce, more well-designed studies that specifically measure child outcomes related to access to pediatric subspecialty care, would add meaningfully to the body of pediatric literature and to our national pediatric advocacy initiatives.

Variation in low-value radiograph use for children in the emergency department: a cross-sectional study of administrative databases

BACKGROUND

Radiograph use contributes to low-value care for children in emergency departments (EDs), but little is known about systemic factors associated with their use. This study compares low-value radiograph use across ED settings by hospital type, pediatric volumes and physician specialty.

METHODS

This is a cross-sectional study of routinely collected administrative data. We included children (age 0-18 yr) discharged from EDs in Ontario, Canada, between 2010 and 2019 with diagnoses of bronchiolitis, asthma, abdominal pain and constipation. Multiple clinical practice guidelines recommend against routine radiograph use in these conditions. Logistic regression evaluated odds of low-value radiograph by ED setting (pediatric academic [referent], adult academic, community with or without pediatric consultation services), pediatric volume and physician specialty (pediatric emergency medicine [PEM, referent], emergency medicine [EM], family medicine with EM training, pediatrics, family medicine), adjusting for demographic, clinical and provider characteristics. We used generalized estimating equations to account for clustering by ED.

RESULTS

Of the total 9 862 787 eligible pediatric ED discharges in Ontario, 60 914 children had bronchiolitis, 141 921 asthma, 333 332 abdominal pain and 110 514 constipation; 26.0% received low-value radiographs. Compared with pediatric EDs and PEM physicians (referents), patients with bronchiolitis were most likely to have a chest radiograph in adult academic EDs (adjusted odds ratio [OR] 5.1 [95% confidence interval (CI) 4.6-5.6]) and by family physicians with EM training (adjusted OR 4.8 [95% CI 4.5-5.1]). Patients with asthma were more likely to have a chest radiograph in adult academic EDs (adjusted OR 3.0 [95% CI 2.8-3.2]) and by EM physicians (adjusted OR 2.8 [95% CI 2.6-3.0]). Patients with abdominal pain and constipation were more likely to have abdominal radiographs in community hospitals with pediatric consultation (adjusted OR 1.6 [95% CI 1.6-1.7] and 2.3 [95% CI 2.3-2.4], respectively) and by family physicians with EM training (adjusted OR 1.6 [95% CI 1.6-1.7] and 2.1 [95% CI 2.0-2.2], respectively).

INTERPRETATION

Over the decade-long study period, low-value radiograph use was frequent for children with 4 common conditions seen in Ontario EDs. Quality improvement initiatives aimed at reducing unnecessary radiographs in children should focus on EM physicians practising in EDs that primarily treat adult patients.

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.

United States' Emergency Department Visits for Fever by Young Children 2007-2017

Introduction

Our goal in this study was to estimate rates of emergency department (ED) visits for fever by children <2 years of age, and evaluate frequencies of testing and treatment during these visits.

Methods

We performed a cross-sectional study of ED encounters from 2007–2017 using the National Hospital Ambulatory Medical Care Survey, a cross-sectional, multi-stage probability sample survey of visits to nonfederal United States EDs. We included encounters with a visit reason of “fever” or recorded fever in the ED. We report demographics and management strategies in two groups: infants ≤90 days in age; and children 91 days to <2 years old. For patients 91 days to <2 years, we compared testing and treatment strategies between general and pediatric EDs using chi-squared tests.

Results

Of 1.5 billion encounters over 11 years, 2.1% (95% confidence interval [CI], 1.9–2.2%) were by children <2 years old with fever. Two million encounters (95% CI, 1.7–2.4 million) were by infants ≤90 days, and 28.4 million (95% CI, 25.5–31.4 million) were by children 91 days to <2 years. Among infants ≤90 days, 27.6% (95% CI, 21.1–34.1%) had blood and 21.3% (95% CI, 13.6–29.1%) had urine cultures; 26.8% (95% CI, 20.9–32.7%) were given antibiotics, and 21.1% (95% CI, 15.3–26.9%) were admitted or transferred. Among patients 91 days to <2 years in age, 6.8% (95% CI, 5.8–7.8%) had blood and 7.7% (95% CI 6.1–9.4%) had urine cultures; 40.5% (95% CI, 40.5–40.5%) were given antibiotics, and 4.4% (95% CI, 3.5–5.3%) were admitted or transferred. Patients 91 days to <2 years who were evaluated in general EDs had higher rates of radiography (27.1% vs 15.2%; P<0.01) and antibiotic utilization (42.3% vs 34.2%; P<0.01), but lower rates of urine culture testing (6.4% vs 11.6%, p = 0.03), compared with patients evaluated in pediatric EDs.

Conclusion

Approximately 180,000 patients ≤90 days old and 2.6 million patients 91 days to <2 years in age with fever present to US EDs annually. Given existing guidelines, blood and urine culture performance was low for infants ≤90 days old. For children 91 days to <2 years, rates of radiography and antibiotic use were higher in general EDs compared to pediatric EDs. These findings suggest opportunities to improve care among febrile young children in the ED.

Epidemiological analysis of croup in the emergency department using two national datasets

OBJECTIVES

To characterize cases of croup presenting to emergency departments (EDs) nationwide, analyze trends, and determine readmission rates.

METHODS

Retrospective review of the Nationwide Emergency Department Sample (2007-2014) and the National Hospital Ambulatory Medical Care Survey (2008-2015).

RESULTS

Both databases provided similar descriptive statistics. Annual mean of 352,388 (weighted) cases in the National Emergency Department Sample (1.35% of ED cases). Average age and male:female ratio 2.50 years and 1.95:1, respectively. Peak incidence was in autumn (October = 13.7%) with troughs in the summer (July = 3.7%). 21.3% received nebulizers, <1% laryngoscopic or airway procedures, 75.1% steroids, and 13.3% antibiotics. Of the patients receiving antibiotics, 16.0% had isolated croup. 3.0% of cases were admitted to the hospital. No trend was identified in the incidence of croup, mean age, or antibiotic and steroid usage. Hospital admission rates decreased (4.0%-2.3%) and nebulizer usage increased (14.6%-27.5%; p < 0.05). 5% of patients represented repeat admissions (were seen within 72 h prior).

CONCLUSIONS

Croup imposes a significant burden on the ED. Although hospital admissions decreased, annual incidence in the ED remained stable. The majority of cases are in males less than three years old, and 5.0% of patients represented readmissions. Only three-quarters received glucocorticoids despite the proven benefits, including reducing readmission rates. Antibiotic usage was high, with a large number representing potential cases of inappropriate antibiotic use.

Antibiotic Prescribing for Children in United States Emergency Departments: 2009-2014

: media-1vid110.1542/5972296744001PEDS-VA_2018-1056Video Abstract OBJECTIVES: To characterize and compare ambulatory antibiotic prescribing for children in US pediatric and nonpediatric emergency departments (EDs).

METHODS

A cross-sectional retrospective study of patients aged 0 to 17 years discharged from EDs in the United States was conducted by using the 2009-2014 National Hospital Ambulatory Medical Care Survey ED data. We estimated the proportion of ED visits resulting in antibiotic prescriptions, stratified by antibiotic spectrum, class, diagnosis, and ED type ("pediatric" defined as >75% of visits by patients aged 0-17 years, versus "nonpediatric"). Multivariable logistic regression was used to determine factors independently associated with first-line, guideline-concordant prescribing for acute otitis media, pharyngitis, and sinusitis.

RESULTS

In 2009-2014, of the 29 million mean annual ED visits by children, 14% (95% confidence interval [CI]: 10%-20%) occurred at pediatric EDs. Antibiotics overall were prescribed more frequently in nonpediatric than pediatric ED visits (24% vs 20%, P < .01). Antibiotic prescribing frequencies were stable over time. Of all antibiotics prescribed, 44% (95% CI: 42%-45%) were broad spectrum, and 32% (95% CI: 30%-34%, 2.1 million per year) were generally not indicated. Compared with pediatric EDs, nonpediatric EDs had a higher frequency of prescribing macrolides (18% vs 8%, P < .0001) and a lower frequency of first-line, guideline-concordant prescribing for the respiratory conditions studied (77% vs 87%, P < .001).

CONCLUSIONS

Children are prescribed almost 7 million antibiotic prescriptions in EDs annually, primarily in nonpediatric EDs. Pediatric antibiotic stewardship efforts should expand to nonpediatric EDs nationwide, particularly regarding avoidance of antibiotic prescribing for conditions for which antibiotics are not indicated, reducing macrolide prescriptions, and increasing first-line, guideline-concordant prescribing.

A Research Agenda to Advance Pediatric Emergency Care Through Enhanced Collaboration Across Emergency Departments

In 2018, the Society for Academic Emergency Medicine and the journal Academic Emergency Medicine (AEM) convened a consensus conference entitled, "Academic Emergency Medicine Consensus Conference: Aligning the Pediatric Emergency Medicine Research Agenda to Reduce Health Outcome Gaps." This article is the product of the breakout session, "Emergency Department Collaboration-Pediatric Emergency Medicine in Non-Children's Hospital"). This subcommittee consisting of emergency medicine, pediatric emergency medicine, and quality improvement (QI) experts, as well as a patient advocate, identified main outcome gaps in the care of children in the emergency departments (EDs) in the following areas: variations in pediatric care and outcomes, pediatric readiness, and gaps in knowledge translation. The goal for this session was to create a research agenda that facilitates collaboration and partnering of diverse stakeholders to develop a system of care across all ED settings with the aim of improving quality and increasing safe medical care for children. The following recommended research strategies emerged: explore the use of technology as well as collaborative networks for education, research, and advocacy to develop and implement patient care guidelines, pediatric knowledge generation and dissemination, and pediatric QI and prepare all EDs to care for the acutely ill and injured pediatric patients. In conclusion, collaboration between general EDs and academic pediatric centers on research, dissemination, and implementation of evidence into clinical practice is a solution to improving the quality of pediatric care across the continuum.

Timing and Location of Emergency Department Revisits

BACKGROUND

Emergency department (ED) revisits are used as a measure of care quality. Many EDs measure only revisits to the same facility, underestimating true rates. We sought to determine the frequency, location, and predictors of ED revisits to the same or a different ED.

METHODS

We studied ED discharges for children <18 years old in Maryland and New York in the statewide ED and inpatient databases. Revisits were defined as ED visits within 7 days of an index visit. Our primary outcome was the proportion of revisits that were different-hospital revisits (DHRs). We measured the underestimation of total revisits when only same-hospital revisits were measured. We determined the risk of DHR by quartile of annual ED pediatric volume, adjusting for case mix, insurance, state, and urban location.

RESULTS

Revisits across 261 EDs occurred after 5.9% of 4.3 million discharges. A per-ED median 21.9% of revisits were DHRs (interquartile range 14.2%-34.6%). Measuring only same-hospital revisits underestimated total revisits by 17.4%. The proportions of revisits that were DHRs by increasing volume quartile were 28.1%, 25.5%, 22.6%, and 14.5%. The adjusted risk of DHR was lower for increasing quartiles of pediatric volume (adjusted odds ratio for highest versus lowest quartile 0.27; 95% confidence interval, 0.19-0.36).

CONCLUSIONS

Measuring ED revisits only at the index ED significantly underestimates total revisits. Lower pediatric volume is associated with higher DHRs as a proportion of revisits. When using revisits as a measure of emergency care quality, effort should be made to assess revisits to different EDs.

The Sensitivity of Clinician Diagnosis of Sepsis in Tertiary and Community-Based Emergency Settings

OBJECTIVES

To assess whether the risk of missed clinician diagnosis of pediatric sepsis requiring care in the intensive care unit (ICU) was greater in community vs tertiary pediatric emergency care settings with sepsis pathways.

STUDY DESIGN

An observational cohort study in a tertiary pediatric emergency department (ED) staffed by pediatric emergency physicians and 4 affiliated community pediatric ED/urgent care sites staffed by general pediatricians. Use of an institutional sepsis order set or pathway was considered clinician diagnosis of sepsis. Risk of missed diagnosis was compared for 2 outcomes: suspected infection plus ICU admission (sepsis-ICU) and suspected infection plus vasoactive agent/positive-pressure ventilation (sepsis-VV).

RESULTS

From January 1, 2014 to December 31, 2015, there were 141 552 tertiary and 139 332 community emergency visits. Clinicians diagnosed sepsis in 1136 visits; median age was 5.7 (2.4, 12.0) years. In the tertiary ED, there were 306 sepsis-ICU visits (0.2%) and 112 sepsis-VV visits (0.08%). In community sites, there were 46 sepsis-ICU visits (0.03%) and 20 sepsis-VV visits (0.01%). The risk of missed diagnosis in community vs tertiary sites was significantly greater for sepsis-ICU (relative risk 4.30, CI 2.15-8.60) and sepsis-VV (relative risk 14.0, CI 2.91-67.24). Sensitivity for sepsis-ICU was 94.4% (91.3%-96.5%) at the tertiary site and 76.1% (62.1%-86.1%) at community sites.

CONCLUSIONS

The risk of missed diagnosis of sepsis-ICU was greater in community vs tertiary emergency care settings despite shared pathways and education, but with differences in resources, providers, and sepsis incidence. More research is needed to optimize diagnostic approaches in all settings.