1
|
Rasouli HR, Aliakbar Esfahani A, Abbasi Farajzadeh M. Challenges, consequences, and lessons for way-outs to emergencies at hospitals: a systematic review study. BMC Emerg Med 2019; 19:62. [PMID: 31666023 PMCID: PMC6822347 DOI: 10.1186/s12873-019-0275-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 10/09/2019] [Indexed: 11/10/2022] Open
Abstract
Background Emergency Department (ED) overcrowding adversely affects patients’ health, accessibility, and quality of healthcare systems for communities. Several studies have addressed this issue. This study aimed to conduct a systematic review study concerning challenges, lessons and way outs of clinical emergencies at hospitals. Methods Original research articles on crowding of emergencies at hospitals published from 1st January 2007, and 1st August 2018 were utilized. Relevant studies from the PubMed and EMBASE databases were assessed using suitable keywords. Two reviewers independently screened the titles, abstracts and the methodological validity of the records using data extraction format before their inclusion in the final review. Discussions with the senior faculty member were used to resolve any disagreements among the reviewers during the assessment phase. Results Out of the total 117 articles in the final record, we excluded 11 of them because of poor quality. Thus, this systematic review synthesized the reports of 106 original articles. Overall 14, 55 and 29 of the reviewed refer to causes, effects, and solutions of ED crowding, respectively. The review also included four articles on both causes and effects and another four on causes and solutions. Multiple individual patients and healthcare system related challenges, experiences and responses to crowding and its consequences are comprehensively synthesized. Conclusion ED overcrowding is a multi-facet issue which affects by patient-related factors and emergency service delivery. Crowding of the EDs adversely affected individual patients, healthcare delivery systems and communities. The identified issues concern organizational managers, leadership, and operational level actions to reduce crowding and improve emergency healthcare outcomes efficiently.
Collapse
Affiliation(s)
- Hamid Reza Rasouli
- Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran.
| | - Ali Aliakbar Esfahani
- Marine Medicine Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | | |
Collapse
|
2
|
|
3
|
Freire G, Kuppermann N, Zemek R, Plint AC, Babl FE, Dalziel SR, Freedman SB, Atenafu EG, Stephens D, Steele DW, Fernandes RM, Florin TA, Kharbanda A, Lyttle MD, Johnson DW, Schnadower D, Macias CG, Benito J, Schuh S. Predicting Escalated Care in Infants With Bronchiolitis. Pediatrics 2018; 142:peds.2017-4253. [PMID: 30126934 DOI: 10.1542/peds.2017-4253] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/21/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Early risk stratification of infants with bronchiolitis receiving airway support is critical for focusing appropriate therapies, yet the tools to risk categorize this subpopulation do not exist. Our objective was to identify predictors of "escalated care" in bronchiolitis. We hypothesized there would be a significant association between escalated care and predictors in the emergency department. We subsequently developed a risk score for escalated care. METHODS We conducted a retrospective cohort study of previously healthy infants aged <12 months with bronchiolitis. Our primary outcome was escalated care (ie, hospitalization with high-flow nasal cannula, noninvasive or invasive ventilation, or intensive care admission). The predictors evaluated were age, prematurity, day of illness, poor feeding, dehydration, apnea, nasal flaring and/or grunting, respiratory rate, oxygen saturation, and retractions. RESULTS Of 2722 patients, 261 (9.6%) received escalated care. Multivariable predictors of escalated care were oxygen saturation <90% (odds ratio [OR]: 8.9 [95% confidence interval (CI) 5.1-15.7]), nasal flaring and/or grunting (OR: 3.8 [95% CI 2.6-5.4]), apnea (OR: 3.0 [95% CI 1.9-4.8]), retractions (OR: 3.0 [95% CI 1.6-5.7]), age ≤2 months (OR: 2.1 [95% CI 1.5-3.0]), dehydration (OR 2.1 [95% CI 1.4-3.3]), and poor feeding (OR: 1.9 [95% CI 1.3-2.7]). One of 217 (0.5%) infants without predictors received escalated care. The risk score ranged from 0 to 14 points, with the estimated risk of escalated care from 0.46% (0 points) to 96.9% (14 points). The area under the curve was 85%. CONCLUSIONS We identified variables measured in the emergency department predictive of escalated care in bronchiolitis and derived a risk score to stratify risk of this outcome. This score may be used to aid management and disposition decisions.
Collapse
Affiliation(s)
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, School of Medicine, University of California, Davis, Sacramento, California
| | - Roger Zemek
- Division of Pediatric Emergency Medicine, University of Ottawa and Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Amy C Plint
- Division of Pediatric Emergency Medicine, University of Ottawa and Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Franz E Babl
- Emergency Department, Royal Children's Hospital, Murdoch Children's Research Institute, Parkville, Australia.,University of Melbourne, Melbourne, Australia
| | - Stuart R Dalziel
- Emergency Department, Starship Children's Hospital and the University of Auckland, Auckland, New Zealand
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Departments of Pediatrics, Alberta Children's Hospital Research Institute, Cumming School of Medicine, Calgary University, Calgary, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Derek Stephens
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Dale W Steele
- Department of Pediatric Emergency Medicine, Hasbro Children's Hospital and Departments of Emergency Medicine, Pediatrics, and Health Services, Policy, and Practice, Brown University, Providence, Rhode Island
| | - Ricardo M Fernandes
- Department of Pediatrics, Hospital de Santa Maria and Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal
| | - Todd A Florin
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Anupam Kharbanda
- Department of Pediatric Emergency Medicine, Children's Hospital of Minnesota, Minneapolis, Minnesota
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children and Faculty of Health and Applied Life Sciences, University of the West of England, Bristol, United Kingdom
| | - David W Johnson
- Sections of Pediatric Emergency Medicine, and Physiology and Pharmacology, Alberta Children's Hospital and Alberta Children's Hospital Research Institute, Cumming School of Medicine, Calgary University, Calgary, Canada
| | - David Schnadower
- Department of Pediatric Emergency Medicine, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Charles G Macias
- Department of Pediatric Emergency Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas; and
| | - Javier Benito
- Pediatric Emergency Department, Cruces University Hospital, Barakaldo, Spain
| | - Suzanne Schuh
- Division of Pediatric Emergency Medicine, and .,Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | | |
Collapse
|
4
|
Rodríguez-Martínez CE, Sossa-Briceño MP, Nino G. Predictors of prolonged length of hospital stay for infants with bronchiolitis. J Investig Med 2018; 66:986-991. [PMID: 29588331 DOI: 10.1136/jim-2018-000708] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2018] [Indexed: 01/03/2023]
Abstract
Among inpatients suffering from bronchiolitis, approximately a quarter may undergo a prolonged length of stay (LOS) for the treatment of their respiratory condition. However, there have been few research studies that have evaluated variables that may be associated with a prolonged LOS in these patients, especially in low-income and middle-income countries, where the clinical and economic burden of the disease is the greatest. In an analytical single-center cross-sectional study, we included a population of patients with acute bronchiolitis hospitalized between March and June 2016. We collected demographic and clinical information and the LOS of each patient. Prolonged LOS for bronchiolitis was defined as at least one hospital stay of 5 or more days. A total of 303 patients were included, with 176 (58.1%) male and a median (IQR) age of 3.0 (1.0-7.0) months. After controlling for gender, history of bronchopulmonary dysplasia, number of days with respiratory symptoms, the presence of apnea as an initial manifestation of bronchiolitis, and other underlying disease conditions, we found that the independent predictors of prolonged LOS for bronchiolitis in our study population included age (OR 0.92; 95% CI 0.84 to 0.99; p=0.049), history of prematurity (OR 6.34; 95% CI 1.10 to 36.46; p=0.038), respiratory syncytial virus isolation (OR 1.92; 95% CI 1.02 to 3.73; p=0.048), and initial oxygen saturation (OR 0.94; 95% CI 0.88 to 0.98; p=0.048). The factors identified should be taken into account when planning policies to reduce the duration of hospital stay in infants with bronchiolitis.
Collapse
Affiliation(s)
- Carlos E Rodríguez-Martínez
- Department of Pediatrics, School of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia.,Department of Pediatric Pulmonology and Pediatric Critical Care Medicine, School of Medicine, Universidad El Bosque, Bogotá, Colombia
| | - Monica P Sossa-Briceño
- Department of Internal Medicine, School of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Gustavo Nino
- Division of Pediatric Pulmonary, Sleep Medicine and Integrative Systems Biology, Center for Genetic Research, Children's National Medical Center, George Washington University, Washington, District of Columbia, USA
| |
Collapse
|
5
|
Schuh S, Babl FE, Dalziel SR, Freedman SB, Macias CG, Stephens D, Steele DW, Fernandes RM, Zemek R, Plint AC, Florin TA, Lyttle MD, Johnson DW, Gouin S, Schnadower D, Klassen TP, Bajaj L, Benito J, Kharbanda A, Kuppermann N. Practice Variation in Acute Bronchiolitis: A Pediatric Emergency Research Networks Study. Pediatrics 2017; 140:peds.2017-0842. [PMID: 29184035 DOI: 10.1542/peds.2017-0842] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/21/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Studies characterizing hospitalizations in bronchiolitis did not identify patients receiving evidence-based supportive therapies (EBSTs). We aimed to evaluate intersite and internetwork variation in receipt of ≥1 EBSTs during the hospital management of infants diagnosed with bronchiolitis in 38 emergency departments of pediatric emergency research networks in Canada, the United States, Australia, New Zealand, the United Kingdom, Ireland, Spain, and Portugal. We hypothesized that there would be significant variation, adjusted for patient characteristics. METHODS Retrospective cohort study of previously healthy infants aged <12 months with bronchiolitis. Our primary outcome was that hospitalization occurred with EBST (ie, parenteral fluids, oxygen, or airway support). RESULTS Out of 3725 participants, 1466 (39%) were hospitalized, and 1023 out of 1466 participants (69.8%) received EBST. The use of EBST varied by site (P < .001; range 6%-99%, median 23%), but not by network (P = .2). Significant multivariable predictors and their odds ratios (ORs) were as follows: age (0.9), oxygen saturation (1.3), apnea (3.4), dehydration (3.2), nasal flaring and/or grunting (2.4), poor feeding (2.1), chest retractions (1.9), and respiratory rate (1.2). The use of pharmacotherapy and radiography varied by network and site (P < .001), with respective intersite ranges 2% to 79% and 1.6% to 81%. Compared with Australia and New Zealand, the multivariable OR for the use of pharmacotherapy in Spain and Portugal was 22.7 (95% confidence interval [CI]: 4.5-111), use in Canada was 11.5 (95% CI: 3.7-36), use in the United States was 6.8 (95% CI: 2.3-19.8), and use in the United Kingdom was 1.4 (95% CI: 0.4-4.2). Compared with United Kingdom, OR for radiography use in the United States was 4.9 (95% CI 2.0-12.2), use in Canada was 4.9 (95% CI 1.9-12.6), use in Spain and Portugal was 2.4 (95% CI 0.6-9.8), and use in Australia and New Zealand was 1.8 (95% CI 0.7-4.7). CONCLUSIONS More than 30% of infants hospitalized with bronchiolitis received no EBST. The hospital site was a source of variation in all study outcomes, and the network also predicted the use of pharmacotherapy and radiography.
Collapse
Affiliation(s)
- Suzanne Schuh
- Division of Paediatric Emergency Medicine and.,The Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Franz E Babl
- Emergency Department, Royal Children's Hospital, Murdoch Children's Research Institute, and University of Melbourne, Melbourne, Australia
| | - Stuart R Dalziel
- Emergency Department, Starship Children's Hospital, and University of Auckland, Auckland, New Zealand
| | | | - Charles G Macias
- Pediatric Emergency Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Derek Stephens
- The Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Dale W Steele
- Section of Pediatric Emergency Medicine, Hasbro Children's Hospital and Section of Pediatric Emergency Medicine, Rhode Island Hospital, Providence, Rhode Island
| | - Ricardo M Fernandes
- Department of Pediatrics, Hospital de Santa Maria and Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal
| | - Roger Zemek
- Division of Pediatric Emergency Medicine, University of Ottawa and Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Amy C Plint
- Division of Pediatric Emergency Medicine, University of Ottawa and Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Todd A Florin
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mark D Lyttle
- Pediatric Emergency Department, Bristol Royal Hospital for Children and Faculty of Health and Life Sciences, University of the West of England, Bristol, United Kingdom
| | - David W Johnson
- Sections of Pediatric Emergency Medicine.,Emergency Medicine, and.,Physiology and Pharmacology, Department of Pediatrics, Alberta Children's Hospital Research Institute and Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Serge Gouin
- Centre hospitalier universitaire Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | - David Schnadower
- Pediatric Emergency Medicine, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Terry P Klassen
- Manitoba Institute of Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lalit Bajaj
- Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado
| | - Javier Benito
- Pediatric Emergency Department, Cruces University Hospital, Barakaldo, Bizkaia, Spain
| | - Anupam Kharbanda
- Emergency Department, Children's Hospital of Minnesota, Minneapolis, Minnesota; and
| | - Nathan Kuppermann
- Departments of Emergency Medicine and.,Pediatrics, Davis School of Medicine, University of California, Sacramento, California
| | | |
Collapse
|
6
|
Stollar F, Gervaix A, Argiroffo CB. Safely Discharging Infants with Bronchiolitis from an Emergency Department: A Five Step Guide for Pediatricians. PLoS One 2016; 11:e0163217. [PMID: 27690359 PMCID: PMC5045212 DOI: 10.1371/journal.pone.0163217] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Accepted: 09/06/2016] [Indexed: 11/24/2022] Open
Abstract
Recent publications have established the pulse oxygen saturation (SpO2) threshold of 90% for the hospitalization and discharge of infant patients with bronchiolitis. However, there is no clear recommendation regarding the Emergency Department (ED) observation period necessary before allowing safe home discharge for patients with SpO2 above 90%-92%. Our primary aims were to evaluate the risk factors associated with delayed desaturation in infants with SpO2 ≥ 92% on arrival at the ED as well as the ED observation period necessary before allowing safe home discharge. A secondary aim was to identify the risk factors for ED readmission. Of 581 episodes of bronchiolitis in patients < 1 year old admitted to the ED, only 47 (8%) had SpO2 < 92% on arrival there, although 106 (18%) exhibited a delayed desaturation (to < 92%) during ED observation. Female sex, age < 3 months old, ED readmission, more severe initial clinical presentation, and higher pCO2 level (> 6KPa) were risk factors for delayed desaturation with OR varying from 1.7 to 7.5. In patients < 3 months old, mean desaturation occured later than in older patients [6.0 hours (IQR 3.0–14.0) vs. 3.0 hours (IQR 2.0–6.0), P = 0.0018]. In 95% of patients with a delayed desaturation this decrease occurred within 25 hours for patients < 3 months old and within 11 hours for patients ≥ 3 months old. In patients < 3 months old with respiratory rates above the normal range for their age the desaturation occurred earlier than in patients < 3 months with normal respiratory rates [4.4 hours (IQR 3.0–11.7) vs. 14.6 hours (IQR 7.6–22.2), P = 0.037]. Based on the present study’s results, we propose a five step guide for pediatricians on discharging children with bronchiolitis from the ED. By using the threshold of an 11 hour ED observation period for patients ≥ 3 months old and a 25 hour period for patients < 3 months old we are able to detect 95% of the patients with bronchiolitis who are at risk of delayed desaturation.
Collapse
Affiliation(s)
- Fabiola Stollar
- General Pediatric Division, Children’s Hospital, University Hospitals of Geneva, Geneva, Switzerland
- * E-mail:
| | - Alain Gervaix
- Pediatric Emergency Division, Children’s Hospital, University Hospitals of Geneva, Geneva, Switzerland
| | | |
Collapse
|
7
|
Prisk D, Godfrey AJR, Lawrence A. Emergency Department Length of Stay for Maori and European Patients in New Zealand. West J Emerg Med 2016; 17:438-48. [PMID: 27429694 PMCID: PMC4944800 DOI: 10.5811/westjem.2016.5.29957] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 04/03/2016] [Accepted: 05/05/2016] [Indexed: 11/27/2022] Open
Abstract
Introduction Emergency department length of stay (ED LOS) is currently used in Australasia as a quality measure. In our ED, Maori, the indigenous people of New Zealand, have a shorter ED LOS than European patients. This is despite Maori having poorer health outcomes overall. This study sought to determine drivers of LOS in our provincial New Zealand ED, particularly looking at ethnicity as a determining factor. Methods This was a retrospective cohort study that reviewed 80,714 electronic medical records of ED patients from December 1, 2012, to December 1, 2014. Univariate and multivariate analyses were carried out on raw data, and we used a complex regression analysis to develop a predictive model of ED LOS. Potential covariates were patient factors, temporal factors, clinical factors, and workload variables (volume and acuity of patients three hours prior to and two hours after presentation by a baseline patient). The analysis was performed using R studio 0.99.467. Results Ethnicity dropped out in the stepwise regression procedure; after adjusting for other factors, a specific ethnicity effect was not informative. Maori were, on average, younger, less likely to receive bloodwork and radiographs, less likely to go to our observation area, less likely to have a general practitioner, and more likely to be discharged and to self-discharge; all of these factors decreased their length of stay. Conclusion Length of stay in our ED does not seem to be related to ethnicity alone. Patient factors had only a small impact on ED LOS, while clinical factors, temporal factors, and workload variables had much greater influence.
Collapse
Affiliation(s)
- David Prisk
- Palmerston North Hospital, Mid Central Health, Emergency Department, Palmerston North, New Zealand
| | | | - Anne Lawrence
- Massey University, Department of Statistics, Palmerston North, New Zealand
| |
Collapse
|
8
|
Zamora-Flores D, Busen NH, Smout R, Velasquez O. Implementing a clinical practice guideline for the treatment of bronchiolitis in a high-risk Hispanic pediatric population. J Pediatr Health Care 2015; 29:169-80. [PMID: 25454385 DOI: 10.1016/j.pedhc.2014.10.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 10/08/2014] [Accepted: 10/10/2014] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Bronchiolitis is the leading cause of hospitalization among infants and young children. Because of its frequency, a clinical practice guideline for bronchiolitis was implemented in this population in an effort to decrease costs and the number of diagnostic evaluations performed and medications used without increasing length of stay or transfers to the pediatric intensive care unit. METHODS A retrospective chart review of 322 pediatric admissions to a rural community hospital was conducted (169 before guideline implementation and 153 after guideline implementation), and data were categorically stratified into three groups for comparison purposes. Descriptive statistics were used to analyze the data, with a p value < .05 defining significance. RESULTS During the project period, patients with a mean age of 9.6 months were admitted to the hospital with bronchiolitis. Statistically significant decreases in cost per day and decreases in use of antibiotics and chest radiographs were achieved without increasing length of stay or pediatric intensive care unit transfers. DISCUSSION This project demonstrated feasibility in implementing an evidence-based clinical practice guideline in a rural hospital to improve patient outcomes.
Collapse
|
9
|
Macias CG, Mansbach JM, Fisher ES, Riederer M, Piedra PA, Sullivan AF, Espinola JA, Camargo CA. Variability in inpatient management of children hospitalized with bronchiolitis. Acad Pediatr 2015; 15:69-76. [PMID: 25444654 DOI: 10.1016/j.acap.2014.07.005] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 07/18/2014] [Accepted: 07/19/2014] [Indexed: 11/29/2022]
Abstract
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.
Collapse
Affiliation(s)
- Charles G Macias
- Department of Pediatrics, Section of Emergency Medicine, and Center for Clinical Effectiveness, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex.
| | - Jonathan M Mansbach
- Department of Medicine, Children's Hospital Boston, Harvard Medical School, Boston, Mass
| | - Erin S Fisher
- Department of Pediatrics, Rady Children's Hospital, University of California, San Diego, Calif
| | - Mark Riederer
- Department of Pediatrics, Children's Hospital of Colorado, Denver, Colo
| | - Pedro A Piedra
- Departments of Molecular Virology and Microbiology, and Pediatrics, Baylor College of Medicine, Houston, Tex
| | - Ashley F Sullivan
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Janice A Espinola
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| |
Collapse
|
10
|
Santiago J, Mansbach JM, Chou SC, Delgado C, Piedra PA, Sullivan AF, Espinola JA, Camargo CA. Racial/ethnic differences in the presentation and management of severe bronchiolitis. J Hosp Med 2014; 9:565-72. [PMID: 24913444 DOI: 10.1002/jhm.2223] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 05/16/2014] [Accepted: 05/20/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVE Bronchiolitis is the leading cause of hospitalization for US infants and is associated with increased risk of childhood asthma. Although studies have shown differences in the presentation and management of asthma across race/ethnicity, it is unclear if such differences are present for bronchiolitis. We examined if racial/ethnic differences exist in the presentation and management of severe bronchiolitis. METHODS We performed a 16-center, prospective cohort study from 2007 to 2010. Children <2 years old hospitalized with a diagnosis of bronchiolitis were included. A structured interview, chart review, and 1-week phone follow-up were completed. Multivariable logistic regression was used to examine the independent association between race/ethnicity and diagnostic imaging, treatment (eg, albuterol, corticosteroids, and continuous positive airway pressure/intubation), management (eg, intensive care unit admission and length of stay), discharge on inhaled corticosteroids, and bronchiolitis relapse. RESULTS Among 2130 patients, 818 (38%) were non-Hispanic white (NHW), 511 (24%) were non-Hispanic black (NHB), and 801 (38%) were Hispanic. Compared with all groups, NHB children were most likely to receive albuterol before admission (odds ratio [OR]: 1.58; 95% confidence interval [CI]: 1.20-2.07) and least likely to receive chest x-rays during hospitalization (OR: 0.66; 95% CI: 0.49-0.90). Hispanic children were most likely to be discharged on inhaled corticosteroids (OR: 1.92; 95% CI: 1.19-3.10). CONCLUSION We observed differences between NHW and minority children regarding preadmission albuterol use, inpatient diagnostic imaging, and prescription of inhaled corticosteroids at discharge, practices that deviate from the American Academy of Pediatrics guidelines. The causes of these differences require further study, but they support implementation of care pathways for severe bronchiolitis.
Collapse
|
11
|
Quality in triage: indicators in patients with respiratory disease. Pediatr Emerg Care 2013; 29:710-4. [PMID: 23714756 DOI: 10.1097/pec.0b013e3182949042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES The objective was to apply quality indicators in respiratory disease triage during a set time period. METHODS This was a retrospective, descriptive, and comparative study of all patients attending the emergency department of Acosta Ñu Children's Hospital with breathing difficulty, between January 1 and July 31, 2011. RESULTS Two thousand five hundred eighty-two patients were included in the study. The delay in medical care according to severity of breathing difficulty was as follows: for critical patients, 1 minute (100% compliance); for emergencies, 6.4 minutes (93.4% compared with 95% standard); for urgencies, 15.8 minutes (90% compared with the standard 90%); and for semiurgencies, 35 minutes (92.4% vs. 85% standard). Regarding to the admission-triage time indicator: mean time was 6.1 minutes; 2220 patients (86%) were classified in less than 10 minutes from the time of hospital admission, and 2453 (95%) were evaluated before 15 minutes. Respiratory rate was recorded in 2368 patients (91.7%), and pulse oximetry in 2443 (94.6%). Both parameters were recorded in 2271 children (88%). Errors in classification were detected, mainly tendency to underestimate the risk or exacerbate the clinical situation; 441 patients underwent subtriage (20.5%), and 44 overtriage (1.7%). There were drawbacks to classify emergencies error rate 45.8% (P < 0.00001). Relationship between pathophysiologic diagnosis and triage level was significant (P < 0.00001). CONCLUSIONS Indicators of triage quality were acceptably met in respiratory disease. Breathing difficulty was identified and classified as urgent, although problems arouse at differentiation between moderate and severe dyspnea.
Collapse
|