Low-Resource Emergency Department Visits for Children With Complex Chronic Conditions

Comparing two definitions of pediatric complexity among children cared for in general and pediatric emergency departments in a statewide sample

Objective

The number of children cared for in emergency departments (EDs) with medical complexity continues to rise. We sought to identify the concordance between 2 commonly used criteria of medical complexity among children presenting to a statewide sample of EDs.

Methods

We conducted a retrospective cross-sectional study of children presenting to a statewide sample of Illinois EDs between 2016 and 2021. We classified patients as having medical complexity when using 2 definitions (≥1 pediatric Complex Chronic Condition [CCC] or complex chronic disease using the Pediatric Medical Complexity Algorithm [PMCA]) and compared their overlap and clinical outcomes.

Results

Of 6,550,296 pediatric ED encounters, CCC criteria and PMCA criteria were met in 217,609 (3.3%) and 175,708 (2.7%) encounters, respectively. Among patients with complexity, 100,015 (34.1%) met both criteria, with moderate agreement (κ = 0.49). Children with complexity by CCC had similar rates of presentation to a pediatric hospital (16.3% vs 14.8%), admission (28.5% vs 33.7%), ICU stay (10.0% vs 10.1%), and in-hospital mortality (0.5% vs 0.5%) compared to children with complexity by PMCA. The most common visit diagnoses for children with CCCs were related to sickle cell disease with crisis (3.9%), abdominal pain (3.6%), and non-specific chest pain (2.7%). The most common diagnoses by PMCA were related to depressive disorders (4.9%), sickle cell disease with crisis (4.8%), and seizures (3.2%).

Conclusions and Relevance

The CCC and PMCA criteria of multisystem complexity identified different populations, with moderate agreement. Careful selection of operational definitions is required for proper application and interpretation in clinical and health services research.

Pediatric Emergency Medicine Physicians' Perspectives on Emergency Care of Children With Medical Complexity: A Multi-institution Mixed-Methods Assessment

OBJECTIVE

Children with medical complexity (CMC) compose 1% of the pediatric population but account for 20% of pediatric emergency department (ED) visits. Previous descriptions of challenges and interventions to ensure quality of care are limited. Our objective was to elicit pediatric emergency medicine (PEM) physicians' perspectives on challenges and opportunities for improvement of emergency care of CMC, with a focus on emergency information forms (EIFs).

METHODS

We conducted a web-based survey of PEM physicians participating the American Academy of Pediatrics Section on Emergency Medicine Survey listserv. The survey was designed using an expert panel, and subsequently piloted and revised to an 18-item survey. Data were analyzed with descriptive statistics.

RESULTS

One hundred fifty-one of 495 respondents (30%) completed the survey. Most respondents (62.9%) reported caring for >10 CMC per month. Whereas overall medical fragility and time constraints were major contributors to the challenges of caring for CMC in the ED, communication with known providers and shared care plans were identified as particularly helpful. Most respondents did not report routine use of EIFs. Anticipated emergencies/action plan was deemed the most important component of EIFs.

CONCLUSIONS

Most PEM physicians view the care for CMC in the ED as challenging despite practicing in high-resource environments. Further research is needed to develop and implement strategies to improve care of CMC in the ED. Understanding experiences of providers in general ED settings is also an important next step given that 80% of CMC present for emergency care outside of major children's hospitals.

Pediatric ED Utilization in a Destination City: Demographic, Clinical, and Temporal Trends

OBJECTIVES

Seasonal variation in emergency department (ED) visits has been shown for a variety of pediatric conditions, but previous studies have not considered how geographic location may also influence when and why these patients present to the ED. Our study examined the demographic and clinical characteristics as well as the seasonal variation among 3 patient populations (locals, in-state nonlocals, and out-of-state visitors) presenting to our pediatric ED (PED), which is located in a coastal, destination city.

METHODS

This was a retrospective chart review of PED visits from June 2014 to June 2019 at the Medical University of South Carolina Children's Hospital, a tertiary care facility located in Charleston, SC. Pediatric ED encounters were divided into 3 groups, depending on the patient's home address: local patients residing in the 3 surrounding metro counties, in-state but nonlocal patients, and out-of-state patients. Demographic and clinical information was abstracted for each visit and compared among the 3 patient groups. Seasonal variation among PED visits was determined by recording the week of the year during which each visit occurred.

RESULTS

Local patients accounted for more than 90% of PED visits with increases in visits from October to April. In-state nonlocal patients presented at consistent rates throughout the year, whereas out-of-state ED utilization peaked significantly during the summer months, Spring Break, Thanksgiving, and Christmas. Our local patient population was majority African American; our in-state nonlocal patients roughly matched our state's racial demographics, and our out-of-state population was predominantly White. Compared with in-state nonlocal patients, our local patients were more likely to present with an infection-related complaint and be diagnosed with lower-acuity conditions such as viral infection, otitis media, upper respiratory infection, cough, fever, and gastroenteritis. In-state nonlocal patients had the highest average triage acuity, more frequently had laboratory tests and imaging ordered, and were more than 4.5 times as likely to be admitted to the hospital compared with our local patients. In-state nonlocal patients were also more likely to present with a psychiatric chief complaint compared with our local patients. Out-of-state patients had a similar overall acuity to local patients but were more likely to have imaging ordered and be diagnosed with injuries such as fractures.

CONCLUSION

At our institution, local patients, in-state nonlocal patients, and out-of-state patients exhibited 3 distinct patterns of PED utilization. Knowledge of these trends can be used to optimize resource allocation and follow-up planning, particularly for our out-of-state patient population.