1
|
Youssef E, Benabbas R, Choe B, Doukas D, Taitt HA, Verma R, Zehtabchi S. Interventions to improve emergency department throughput and care delivery indicators: A systematic review and meta-analysis. Acad Emerg Med 2024. [PMID: 38826092 DOI: 10.1111/acem.14946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 04/19/2024] [Accepted: 05/10/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND Emergency department (ED) crowding has repercussions on acute care, contributing to prolonged wait times, length of stay, and left without being seen (LWBS). These indicators are regarded as systemic shortcomings, reflecting a failure to provide equitable and accessible acute care. The objective was to evaluate the effectiveness of interventions aimed at improving ED care delivery indicators. METHODS This was a systematic review and meta-analysis of randomized controlled trials (RCTs) assessing ED interventions aimed at reducing key metrics of time to provider (TTP), time to disposition (TTD), and LWBS. We excluded disease-specific trials (e.g., stroke). We used Cochrane's revised tool to assess the risk of bias and Grading of Recommendations, Assessment, Development, and Evaluations to rate the quality of evidence. The meta-analysis was performed using a random-effects model and Cochrane Q test for heterogeneity. Data were summarized as means (±SD) for continuous variables and risk ratios (RR) with 95% confidence intervals (CIs). RESULTS We searched MEDLINE, EMBASE, and other major databases. A total of 1850 references were scanned and 20 RCTs were selected for inclusion. The trials reported at least one of the three outcomes of TTD, TTP, or LWBS. Most interventions focused on triage liaison physician and point-of-care (POC) testing. Others included upfront expedited workup (ordering tests before full evaluation by a provider), scribes, triage kiosks, and sending notifications to consultants or residents. POC testing decreased TTD by an average of 5-96 min (high heterogeneity) but slightly increased TTP by a mean difference of 2 min (95% CI 0.6-4 min). Utilizing a triage liaison physician reduced TTD by 28 min (95% CI 19-37 min; moderate-quality evidence) and was more effective in reducing LWBS than routine triage (RR 0.76, 95% CI 0.66-0.88; moderate quality). CONCLUSIONS Operational strategies such as POC testing and triage liaison physicians could mitigate the impact of ED crowding and appear to be effective. The current evidence supports these strategies when tailored to the appropriate practice environment.
Collapse
Affiliation(s)
- Elias Youssef
- Department of Emergency Medicine, New York Health + Hospitals/Kings County Hospital, Brooklyn, New York, USA
| | - Roshanak Benabbas
- Department of Emergency Medicine, New York Health + Hospitals/Kings County Hospital, Brooklyn, New York, USA
| | - Brittany Choe
- Department of Emergency Medicine, New York Health + Hospitals/Kings County Hospital, Brooklyn, New York, USA
| | - Donald Doukas
- Department of Emergency Medicine, New York Health + Hospitals/Kings County Hospital, Brooklyn, New York, USA
| | - Hope A Taitt
- Department of Emergency Medicine, New York Health + Hospitals/Kings County Hospital, Brooklyn, New York, USA
| | - Rajesh Verma
- Department of Emergency Medicine, New York Health + Hospitals/Kings County Hospital, Brooklyn, New York, USA
| | - Shahriar Zehtabchi
- Department of Emergency Medicine, New York Health + Hospitals/Kings County Hospital, Brooklyn, New York, USA
| |
Collapse
|
2
|
Kappy B, McKinley K, Chamberlain J, Isbey S. Response to "Diverging Trends in Left Without Being Seen Rates During the Pandemic Era: Emergency Department Length of Stay May Be a Key Factor". J Emerg Med 2024; 66:e547-e548. [PMID: 38580417 DOI: 10.1016/j.jemermed.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 11/23/2023] [Indexed: 04/07/2024]
Affiliation(s)
- Brandon Kappy
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia
| | - Kenneth McKinley
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia
| | - James Chamberlain
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia
| | - Sarah Isbey
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia
| |
Collapse
|
3
|
Amjad S, Tromburg C, Adesunkanmi M, Mawa J, Mahbub N, Campbell S, Chari R, Rowe BH, Ospina MB. Social Determinants of Health and Pediatric Emergency Department Outcomes: A Systematic Review and Meta-Analysis of Observational Studies. Ann Emerg Med 2024; 83:291-313. [PMID: 38069966 DOI: 10.1016/j.annemergmed.2023.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 10/03/2023] [Accepted: 10/20/2023] [Indexed: 03/24/2024]
Abstract
STUDY OBJECTIVE Social determinants of health contribute to disparities in pediatric health and health care. Our objective was to synthesize and evaluate the evidence on the association between social determinants of health and emergency department (ED) outcomes in pediatric populations. METHODS This review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Equity Extension guidelines. Observational epidemiological studies were included if they examined at least 1 social determinant of health from the PROGRESS-Plus framework in relation to ED outcomes among children <18 years old. Effect direction plots were used for narrative results and pooled odds ratios (pOR) with 95% confidence intervals (CI) for meta-analyses. RESULTS Fifty-eight studies were included, involving 17,275,090 children and 103,296,839 ED visits. Race/ethnicity and socioeconomic status were the most reported social determinants of health (71% each). Black children had 3 times the odds of utilizing the ED (pOR 3.16, 95% CI 2.46 to 4.08), whereas visits by Indigenous children increased the odds of departure prior to completion of care (pOR 1.58, 95% CI 1.39 to 1.80) compared to White children. Public insurance, low income, neighborhood deprivation, and proximity to an ED were also predictors of ED utilization. Children whose caregivers had a preferred language other than English had longer length of stay and increased hospital admission. CONCLUSION Social determinants of health, particularly race, socioeconomic deprivation, proximity to an ED, and language, play important roles in ED care-seeking patterns of children and families. Increased utilization of ED services by children from racial minority and lower socioeconomic status groups may reflect barriers to health insurance and access to health care, including primary and subspecialty care, and/or poorer overall health, necessitating ED care. An intersectional approach is needed to better understand the trajectories of disparities in pediatric ED outcomes and to develop, implement, and evaluate future policies.
Collapse
Affiliation(s)
- Sana Amjad
- Department of Obstetrics & Gynecology, University of Alberta, Edmonton, Alberta, Canada
| | - Courtney Tromburg
- Department of Obstetrics & Gynecology, University of Alberta, Edmonton, Alberta, Canada
| | - Maryam Adesunkanmi
- Department of Obstetrics & Gynecology, University of Alberta, Edmonton, Alberta, Canada
| | - Jannatul Mawa
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Nazif Mahbub
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Sandra Campbell
- John W. Scott Health Sciences Library, University of Alberta, Edmonton, Alberta, Canada
| | - Radha Chari
- Department of Obstetrics & Gynecology, University of Alberta, Edmonton, Alberta, Canada
| | - Brian H Rowe
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada; Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Maria B Ospina
- Department of Obstetrics & Gynecology, University of Alberta, Edmonton, Alberta, Canada; Department of Public Health Sciences, Queen's University; Kingston, Ontario, Canada.
| |
Collapse
|
4
|
Kappy B, McKinley K, Chamberlain J, Badolato GM, Podolsky RH, Bond G, Schultz TR, Isbey S. Leaving Without Being Seen From the Pediatric Emergency Department: A New Baseline. J Emerg Med 2023; 65:e237-e249. [PMID: 37659902 DOI: 10.1016/j.jemermed.2023.05.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/05/2023] [Accepted: 05/26/2023] [Indexed: 09/04/2023]
Abstract
BACKGROUND Left without being seen (LWBS) rates are an important quality metric for pediatric emergency departments (EDs), with high-acuity LWBS children representing a patient safety risk. Since July 2021, our ED experienced a surge in LWBS after the most stringent COVID-19 quarantine restrictions ended. OBJECTIVE We assessed changes in LWBS rates and examined associations of system factors and patient characteristics with LWBS. METHODS We performed a retrospective study in a large, urban pediatric ED for all arriving patients, comparing the following three time-periods: before COVID-19 (PRE, January 2018-February 2020), during early COVID-19 (COVID, March 2020-June 2021), and after the emergence of COVID-19 variants and re-emergence of seasonal viruses (POST, July 2021-December 2021). We compared descriptive statistics of daily LWBS rates, patient demographic characteristics, and system characteristics. Negative binomial (system factors) and logistic regression (patient characteristics) models were developed to evaluate the associations between system factors and LWBS, and patient characteristics and LWBS, respectively. RESULTS Mean daily LWBS rates changed from 1.8% PRE to 1.4% COVID to 10.7% during POST. Rates increased across every patient demographic and triage level during POST, despite a decrease in daily ED volume compared with PRE. LWBS rates were significantly associated with patients with an Emergency Severity Index score of 2, mean ED census, and staff productivity within multiple periods. Patient characteristics associated with LWBS included lower assigned triage levels and arrival between 8 pm and 4 am. CONCLUSIONS LWBS rates have shown a large and sustained increase since July 2021, even for high-acuity patients. We identified system factors that may provide opportunities to reduce LWBS. Further work should develop strategies to prevent LWBS in at-risk patients.
Collapse
Affiliation(s)
- Brandon Kappy
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia.
| | - Kenneth McKinley
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia
| | - James Chamberlain
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia
| | - Gia M Badolato
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia
| | - Robert H Podolsky
- Division of Biostatistics and Study Methodology, Center for Translational Research, Children's National Hospital, Washington, District of Columbia
| | - Gregory Bond
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia
| | - Theresa Ryan Schultz
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia
| | - Sarah Isbey
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia
| |
Collapse
|
5
|
Jefferson AA, Brown CC, Eyimina A, Goudie A, Rezaeiahari M, Perry TT, Tilford JM. Asthma Quality Measurement and Adverse Outcomes in Medicaid-Enrolled Children. Pediatrics 2023:e2022059812. [PMID: 37497577 PMCID: PMC10389769 DOI: 10.1542/peds.2022-059812] [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] [Accepted: 05/17/2023] [Indexed: 07/28/2023] Open
Abstract
OBJECTIVES To determine the association between the asthma medication ratio (AMR) quality measure and adverse outcomes among Medicaid-enrolled children with asthma in Arkansas, given concerns regarding the utility of the AMR in evaluating pediatric risk of asthma-related adverse events (AAEs). METHODS We used the Arkansas All-Payer Claims Database to identify Medicaid-enrolled children with asthma using a nonrestrictive case definition and additionally using the standard Healthcare Effectiveness Data and Information Set (HEDIS) persistent asthma definition. We assessed the AMR using the traditional dichotomous HEDIS AMR categorization and across 4 expanded AMR categories. Regression models assessed associations between AMR and AAE including hospitalization and emergency department utilization, with models conducted overall and by race and ethnicity. RESULTS Of the 22 788 children in the analysis, 9.0% had an AAE (6.7% asthma-related emergency department visits; 3.0% asthma-related hospitalizations). We found poor correlation between AMR and AAE, with higher rates of AAE (10.5%) among children with AMR ≥0.5 compared with AMR <0.5 (8.5%; P < .001), and similar patterns stratified by racial and ethnic subgroups. Expanded AMR categorization revealed notable differences in associations between AMR and AAEs, compared with traditional dichotomous categorization, with worse performance in Black children. CONCLUSIONS The AMR performed poorly in identifying risk of adverse outcomes among Medicaid-enrolled children with asthma. These findings underscore concerns of the utility of the AMR in population health management and reliance on restrictive HEDIS definitions. New population health frameworks incorporating broader considerations that accurately identify at-risk children are needed to improve equity in asthma management and outcomes.
Collapse
Affiliation(s)
- Akilah A Jefferson
- Department of Pediatrics, Allergy & Immunology Division
- Arkansas Children's Research Institute, Little Rock, Arkansas
| | - Clare C Brown
- College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas; and
| | - Arina Eyimina
- College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas; and
| | - Anthony Goudie
- College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas; and
| | - Mandana Rezaeiahari
- College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas; and
| | - Tamara T Perry
- Department of Pediatrics, Allergy & Immunology Division
- Arkansas Children's Research Institute, Little Rock, Arkansas
| | - J Mick Tilford
- College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas; and
| |
Collapse
|
6
|
Abstract
OBJECTIVES Health disparities between racial and ethnic groups have been documented in Canada, the United States, and Australia. Despite evidence that differences in emergency department (ED) care based on patient race and ethnicity exist, there are no comprehensive literature reviews in this area. The objective of this review is to provide an overview of the literature on the impact of patient ethnicity and race on the processes of ED care. METHODS A scoping review was conducted to capture the broad nature of the literature. A database search was conducted in MEDLINE/PubMed, EMBASE, CINAHL Plus, Social Sciences Citation Index, SCOPUS, and JSTOR. Five journals and reference lists of included articles were hand searched. Inclusion and exclusion criteria were defined iteratively to ensure literature captured was relevant to our research question. Data were extracted using predetermined variables, and additional extraction variables were added as familiarity with the literature developed. RESULTS Searching yielded 1,157 citations, reduced to 153 following removal of duplicates, and title and abstract screening. After full-text screening, 83 articles were included. Included articles report that, in EDs, patient race and ethnicity impact analgesia, triage scores, wait times, treatments, diagnostic procedure utilization, rates of patients leaving without being seen, and patient subjective experiences. Authors of included studies propose a variety of possible causes for these disparities. CONCLUSIONS Further research on the existence of disparities in care within EDs is warranted to explore the causes behind observed disparities for particular health conditions and population groups in specific contexts.
Collapse
|
7
|
First Nations emergency care in Alberta: descriptive results of a retrospective cohort study. BMC Health Serv Res 2021; 21:423. [PMID: 33947385 PMCID: PMC8096356 DOI: 10.1186/s12913-021-06415-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 04/19/2021] [Indexed: 11/17/2022] Open
Abstract
Background Worse health outcomes are consistently reported for First Nations people in Canada. Social, political and economic inequities as well as inequities in health care are major contributing factors to these health disparities. Emergency care is an important health services resource for First Nations people. First Nations partners, academic researchers, and health authority staff are collaborating to examine emergency care visit characteristics for First Nations and non-First Nations people in the province of Alberta. Methods We conducted a population-based retrospective cohort study examining all Alberta emergency care visits from April 1, 2012 to March 31, 2017 by linking administrative data. Patient demographics and emergency care visit characteristics for status First Nations persons in Alberta, and non-First Nations persons, are reported. Frequencies and percentages (%) describe patients and visits by categorical variables (e.g., Canadian Triage and Acuity Scale). Means, medians, standard deviations and interquartile ranges describe continuous variables (e.g., age). Results The dataset contains 11,686,288 emergency care visits by 3,024,491 unique persons. First Nations people make up 4% of the provincial population and 9.4% of provincial emergency visits. The population rate of emergency visits is nearly 3 times higher for First Nations persons than non-First Nations persons. First Nations women utilize emergency care more than non-First Nations women (54.2% of First Nations visits are by women compared to 50.9% of non-First Nations visits). More First Nations visits end in leaving without completing treatment (6.7% v. 3.6%). Conclusions Further research is needed on the impact of First Nations identity on emergency care drivers and outcomes, and on emergency care for First Nations women. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06415-2.
Collapse
|
8
|
Javalkar K, Robson VK, Gaffney L, Bohling AM, Arya P, Servattalab S, Roberts JE, Campbell JI, Sekhavat S, Newburger JW, de Ferranti SD, Baker AL, Lee PY, Day-Lewis M, Bucholz E, Kobayashi R, Son MB, Henderson LA, Kheir JN, Friedman KG, Dionne A. Socioeconomic and Racial and/or Ethnic Disparities in Multisystem Inflammatory Syndrome. Pediatrics 2021; 147:peds.2020-039933. [PMID: 33602802 PMCID: PMC8086000 DOI: 10.1542/peds.2020-039933] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2021] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES To characterize the socioeconomic and racial and/or ethnic disparities impacting the diagnosis and outcomes of multisystem inflammatory syndrome in children (MIS-C). METHODS This multicenter retrospective case-control study was conducted at 3 academic centers from January 1 to September 1, 2020. Children with MIS-C were compared with 5 control groups: children with coronavirus disease 2019, children evaluated for MIS-C who did not meet case patient criteria, children hospitalized with febrile illness, children with Kawasaki disease, and children in Massachusetts based on US census data. Neighborhood socioeconomic status (SES) and social vulnerability index (SVI) were measured via a census-based scoring system. Multivariable logistic regression was used to examine associations between SES, SVI, race and ethnicity, and MIS-C diagnosis and clinical severity as outcomes. RESULTS Among 43 patients with MIS-C, 19 (44%) were Hispanic, 11 (26%) were Black, and 12 (28%) were white; 22 (51%) were in the lowest quartile SES, and 23 (53%) were in the highest quartile SVI. SES and SVI were similar between patients with MIS-C and coronavirus disease 2019. In multivariable analysis, lowest SES quartile (odds ratio 2.2 [95% confidence interval 1.1-4.4]), highest SVI quartile (odds ratio 2.8 [95% confidence interval 1.5-5.1]), and racial and/or ethnic minority background were associated with MIS-C diagnosis. Neither SES, SVI, race, nor ethnicity were associated with disease severity. CONCLUSIONS Lower SES or higher SVI, Hispanic ethnicity, and Black race independently increased risk for MIS-C. Additional studies are required to target interventions to improve health equity for children.
Collapse
Affiliation(s)
- Karina Javalkar
- Departments of Medicine and,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts;,Department of Pediatrics, Boston University, Boston, Massachusetts;,Contributed equally as co-first authors
| | - Victoria K. Robson
- Departments of Medicine and,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts;,Department of Pediatrics, Boston University, Boston, Massachusetts;,Contributed equally as co-first authors
| | - Lukas Gaffney
- Departments of Medicine and,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts;,Department of Pediatrics, Boston University, Boston, Massachusetts
| | - Amy M. Bohling
- Cardiology, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Puneeta Arya
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts;,Division of Cardiology and
| | - Sarah Servattalab
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts;,Massachusetts General Hospital for Children, Massachusetts General Hospital, Boston, Massachusetts; and
| | - Jordan E. Roberts
- Divisions of Immunology and,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Jeffrey I. Campbell
- Infectious Diseases and,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Sepehr Sekhavat
- Department of Pediatrics, Boston University, Boston, Massachusetts;,Department of Cardiology, Boston Medical Center, Boston, Massachusetts
| | - Jane W. Newburger
- Cardiology, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Sarah D. de Ferranti
- Cardiology, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Annette L. Baker
- Cardiology, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Pui Y. Lee
- Divisions of Immunology and,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Megan Day-Lewis
- Divisions of Immunology and,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Emily Bucholz
- Cardiology, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Ryan Kobayashi
- Cardiology, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Mary Beth Son
- Divisions of Immunology and,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Lauren A. Henderson
- Divisions of Immunology and,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - John N. Kheir
- Cardiology, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Kevin G. Friedman
- Cardiology, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Audrey Dionne
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts; .,Cardiology, Boston Children's Hospital, Boston, Massachusetts
| |
Collapse
|
9
|
Stephen JM, Zoucha R. Spanish Speaking, Limited English Proficient Parents whose Children are Hospitalized: An Integrative Review. J Pediatr Nurs 2020; 52:30-40. [PMID: 32163844 DOI: 10.1016/j.pedn.2020.02.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 02/16/2020] [Accepted: 02/18/2020] [Indexed: 12/14/2022]
Abstract
PROBLEM Children of non-English speakers are at risk for health disparities. Little is known about the experiences of Spanish speaking parents with limited English proficiency (LEP) whose children are hospitalized. The purposes of this integrative review were to explore what is known and to identify gaps in the literature about the experiences of Spanish speaking parents with LEP whose children are hospitalized. ELIGIBILITY CRITERIA Whittemore and Knafl's (2005) integrative review method guided the process. Studies addressed Spanish speaking parents of hospitalized children in the United States. SAMPLE A final sample consisted of 36 quantitative and qualitative research studies published from 1994 to 2018; located through a search of CINAHL, Pubmed, and Scopus. RESULTS Language services were inconsistent although mandated by standards and laws. Parents experienced mixed emotions related to care. Emergency departments in large, urban cities were the most common care settings. Differences in care outcomes and safety risks for children of Spanish speaking parents existed; however, findings were inconsistent. Only three of the 36 studies addressed nursing care. CONCLUSIONS Research design and quality varied. Parents valued communication in their language. Nurses are the primary healthcare provider in the hospital setting but few studies explored parents' experiences associated with nursing care. No studies explored parents' experiences with their child's hospitalization in the context of culture. IMPLICATIONS Future research is needed to explore the cultural values, beliefs, and experiences of Spanish speaking parents with LEP and the role of nurses and to inform culturally congruent nursing care, research, and policy.
Collapse
|
10
|
McMichael B, Nickel A, Duffy EA, Skjefte L, Lee L, Park P, Nelson SC, Puumala S, Kharbanda AB. The Impact of Health Equity Coaching on Patient's Perceptions of Cultural Competency and Communication in a Pediatric Emergency Department: An Intervention Design. J Patient Exp 2018; 6:257-264. [PMID: 31853480 PMCID: PMC6908992 DOI: 10.1177/2374373518798111] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Purpose American Indian (AI) children experience significant disparities in health-care access. As a result, they are more likely to use the emergency department (ED) for nonemergent visits than white children. In a recent study, pediatric ED providers have shown an implicit bias for white children over AI children. To combat implicit bias in an ED setting, we created a protocol for training ED providers as health equity coaches. Methods The intervention took place during the fall of 2016 and was composed of 4 educational lectures, 6 to 8 hours of service learning in AI communities, and the participant's dissemination of what was learned through formal presentations and informal conversations with other ED staff. We measured the impact of this intervention on the intervention participants with a group interview at the completion of the intervention. Results The findings from the group interview provide feedback on what was learned during the intervention, how it impacted providers, and feedback on the structure of the intervention. Overall ED providers reported the intervention improved awareness of their implicit bias and ways to improve communication and care for AI patients. Additional institutional policy and procedural changes are necessary to effectively and sustainably address health disparities affecting AI populations. Conclusions The participating providers identified their lack of knowledge regarding AI cultures at the start of the intervention and it became clear that their knowledge, comfort, and relationships with AI communities increased as a result of this intervention.
Collapse
Affiliation(s)
- Brianna McMichael
- Children's Minnesota Research Institute, Children's Minnesota, Minneapolis, MN, USA
| | - Amanda Nickel
- Children's Minnesota Research Institute, Children's Minnesota, Minneapolis, MN, USA
| | - Elizabeth A Duffy
- Children's Minnesota Research Institute, Children's Minnesota, Minneapolis, MN, USA
| | - Lisa Skjefte
- Department of Advocacy and Child Health Policy, Children's Minnesota, Minneapolis, MN, USA
| | - Lor Lee
- Department of Inclusion and Equity, Children's Minnesota, Minneapolis, MN, USA
| | - Patina Park
- Minnesota Indian Women's Resource Center, Minneapolis, MN, USA
| | - Stephen C Nelson
- Department of Pediatric Hematology and Oncology, Children's Minnesota, Minneapolis, MN, USA
| | - Susan Puumala
- Center for Health Outcomes and Prevention Research, Sanford Research, Sioux Falls, SD, USA
| | - Anupam B Kharbanda
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN, USA
| |
Collapse
|
11
|
Leaving the emergency department without complete care: disparities in American Indian children. BMC Health Serv Res 2018; 18:267. [PMID: 29636036 PMCID: PMC5894126 DOI: 10.1186/s12913-018-3092-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 04/03/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Children who leave the emergency department (ED) without complete evaluation or care (LWCET) have poorer outcomes in general. Previous studies have found that American Indian (AI) children have higher rates of LWCET than other racial or ethnic groups. Therefore, this study aims to examine LWCET in AI children by exploring differences by ED location and utilization patterns. METHODS This is a retrospective cohort study of five EDs in the upper Midwest between June 2011 and May 2012. We included all visits by children aged 0-17 who identified as African American (AA), AI or White. Logistic regression was used to determine differences in LWCET by race and ED location controlling for other possible confounding factors including sex, age, insurance type, triage level, distance from ED, timing of visit, and ED activity level. RESULTS LWCET occurred in 1.73% of 68,461 visits made by 47,228 children. The multivariate model revealed that AIs were more likely to LWCET compared to White children (Odds Ratio (OR) = 1.62, 95% Confidence Interval (CI) = 1.30-2.03). There was no significant difference in LWCET between AA and White children. Other factors significantly associated with LWCET included triage level, distance from the ED, timing of visit, and ED activity level. CONCLUSION Our results show that AI children have higher rates of LWCET compared to White children; this association is different from other racial minority groups. There are likely complex factors affecting LWCET in AI children throughout the upper Midwest, which necessitates further exploration.
Collapse
|
12
|
Marcin JP, Romano PS, Dayal P, Dharmar M, Chamberlain JM, Dudley N, Macias CG, Nigrovic LE, Powell EC, Rogers AJ, Sonnett M, Tzimenatos L, Alpern ER, Andrews‐Dickert R, Borgialli DA, Sidney E, Charles Casper T, Michael Dean J, Kuppermann N. Patient-level Factors and the Quality of Care Delivered in Pediatric Emergency Departments. Acad Emerg Med 2018; 25:301-309. [PMID: 29150972 DOI: 10.1111/acem.13347] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 11/06/2017] [Accepted: 11/12/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Quality of care delivered to adult patients in the emergency department (ED) is often associated with demographic and clinical factors such as a patient's race/ethnicity and insurance status. We sought to determine whether the quality of care delivered to children in the ED was associated with a variety of patient-level factors. METHODS This was a retrospective, observational cohort study. Pediatric patients (<18 years) who received care between January 2011 and December 2011 at one of 12 EDs participating in the Pediatric Emergency Care Applied Research Network (PECARN) were included. We analyzed demographic factors (including age, sex, and payment source) and clinical factors (including triage, chief complaint, and severity of illness). We measured quality of care using a previously validated implicit review instrument using chart review with a summary score that ranged from 5 to 35. We examined associations between demographic and clinical factors and quality of care using a hierarchical multivariable linear regression model with hospital site as a random effect. RESULTS In the multivariable model, among the 620 ED encounters reviewed, we did not find any association between patient age, sex, race/ethnicity, and payment source and the quality of care delivered. However, we did find that some chief complaint categories were significantly associated with lower than average quality of care, including fever (-0.65 points in quality, 95% confidence interval [CI] = -1.24 to -0.06) and upper respiratory symptoms (-0.68 points in quality, 95% CI = -1.30 to -0.07). CONCLUSION We found that quality of ED care delivered to children among a cohort of 12 EDs participating in the PECARN was high and did not differ by patient age, sex, race/ethnicity, and payment source, but did vary by the presenting chief complaint.
Collapse
Affiliation(s)
- James P. Marcin
- Department of Pediatrics University of California, Davis School of Medicine Sacramento CA
| | - Patrick S. Romano
- Department of Pediatrics University of California, Davis School of Medicine Sacramento CA
- Department of Internal Medicine University of California, Davis School of Medicine Sacramento CA
| | - Parul Dayal
- Department of Pediatrics University of California, Davis School of Medicine Sacramento CA
| | - Madan Dharmar
- Department of Pediatrics University of California, Davis School of Medicine Sacramento CA
| | | | - Nanette Dudley
- Department of Pediatrics University of Utah School of Medicine Salt Lake City UT
| | - Charles G. Macias
- Department of Pediatrics and Center for Clinical Effectiveness Baylor College of Medicine Houston TX
| | - Lise E. Nigrovic
- Division of Emergency Medicine Boston Children's Hospital Boston MA
| | - Elizabeth C. Powell
- Department of Pediatrics Northwestern University's Feinberg School of Medicine Chicago IL
| | - Alexander J. Rogers
- Departments of Emergency Medicine and Pediatrics University of Michigan Ann Arbor MI
| | - Meridith Sonnett
- Department of Pediatrics Columbia University Medical Center Columbia University College of Physicians and Surgeons New York NY
| | - Leah Tzimenatos
- Department of Emergency Medicine University of California, Davis School of Medicine Sacramento CA
| | - Elizabeth R. Alpern
- Department of Pediatrics The Children's Hospital of Philadelphia University of Pennsylvania School of Medicine Philadelphia PA
| | - Rebecca Andrews‐Dickert
- Department of Emergency Medicine DeVos Children's Hospital Michigan State University College of Human Medicine Grand Rapids MI
| | - Dominic A. Borgialli
- Department of Emergency Medicine Hurley Medical Center and University of Michigan Flint MI
| | - Erika Sidney
- Division of Emergency Medicine Children's Hospital Colorado University of Colorado AuroraCO
| | - T. Charles Casper
- Department of Pediatrics University of Utah and PECARN Data Coordinating Center Salt Lake City UT
| | - J. Michael Dean
- Department of Pediatrics University of Utah and PECARN Data Coordinating Center Salt Lake City UT
| | - Nathan Kuppermann
- Department of Pediatrics University of California, Davis School of Medicine Sacramento CA
- Department of Emergency Medicine University of California, Davis School of Medicine Sacramento CA
| | | |
Collapse
|
13
|
Abstract
BACKGROUND American Indian children have high rates of emergency department (ED) use and face potential discrimination in health care settings. OBJECTIVE Our goal was to assess both implicit and explicit racial bias and examine their relationship with clinical care. RESEARCH DESIGN We performed a cross-sectional survey of care providers at 5 hospitals in the Upper Midwest. Questions included American Indian stereotypes (explicit attitudes), clinical vignettes, and the Implicit Association Test. Two Implicit Association Tests were created to assess implicit bias toward the child or the parent/caregiver. Differences were assessed using linear and logistic regression models with a random effect for study site. RESULTS A total of 154 care providers completed the survey. Agreement with negative American Indian stereotypes was 22%-32%. Overall, 84% of providers had an implicit preference for non-Hispanic white adults or children. Older providers (50 y and above) had lower implicit bias than those middle aged (30-49 y) (P=0.01). American Indian children were seen as increasingly challenging (P=0.04) and parents/caregivers less compliant (P=0.002) as the proportion of American Indian children seen in the ED increased. Responses to the vignettes were not related to implicit or explicit bias. CONCLUSIONS The majority of ED care providers had an implicit preference for non-Hispanic white children or adults compared with those who were American Indian. Provider agreement with negative American Indian stereotypes differed by practice and respondents' characteristics. These findings require additional study to determine how these implicit and explicit biases influence health care or outcomes disparities.
Collapse
|
14
|
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
|
15
|
Zook HG, Kharbanda AB, Flood A, Harmon B, Puumala SE, Payne NR. Racial Differences in Pediatric Emergency Department Triage Scores. J Emerg Med 2016; 50:720-7. [PMID: 26899520 DOI: 10.1016/j.jemermed.2015.02.056] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 01/19/2015] [Accepted: 02/27/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Racial disparities are frequently reported in emergency department (ED) care. OBJECTIVES To examine racial differences in triage scores of pediatric ED patients. We hypothesized that racial differences existed but could be explained after adjusting for sociodemographic and clinical factors. METHODS We examined all visits to two urban, pediatric EDs between August 2009 and March 2010. Demographic and clinical data were electronically extracted from the medical record. We used logistic regression to analyze racial differences in triage scores, controlling for possible covariates. RESULTS There were 54,505 ED visits during the study period, with 7216 (13.2%) resulting in hospital admission. White patients accounted for 36.4% of visits, African Americans 28.5%, Hispanics 18.0%, Asians 4.1%, and American Indians 1.8%. After adjusting for potential confounders, African American (adjusted odds ratio [aOR] 1.89, 95% confidence interval [CI] 1.69-2.12), Hispanic (aOR 1.77, 95% CI 1.55-2.02), and American Indian (aOR 2.57, 95% CI 1.80-3.66) patients received lower-acuity triage scores than Whites. In three out of four subgroup analyses based on presenting complaints (breathing difficulty, abdominal pain, fever), African Americans and Hispanics had higher odds of receiving low-acuity triage scores. No racial differences were detected for patients with presenting complaints of laceration/head injury/arm injury. However, among patients admitted to the hospital, African Americans (aOR 1.47, 95% CI 1.13-1.90) and Hispanics (aOR 1.71, CI 1.22-2.39) received lower-acuity triage scores than Whites. CONCLUSION After adjusting for available sociodemographic and clinical covariates, African American, Hispanic, and American Indian patients received lower-acuity triage scores than Whites.
Collapse
Affiliation(s)
- Heather G Zook
- Department of Research and Sponsored Programs, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - Anupam B Kharbanda
- Department of Emergency Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - Andrew Flood
- Department of Research and Sponsored Programs, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - Brian Harmon
- Department of Quality and Safety, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - Susan E Puumala
- Center for Health Outcomes and Prevention Research, Sanford Research, Sioux Falls, South Dakota; Department of Pediatrics, Sanford School of Medicine of the University of South Dakota, Sioux Falls, South Dakota
| | - Nathaniel R Payne
- Department of Research and Sponsored Programs, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota; Department of Quality and Safety, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| |
Collapse
|
16
|
Payne NR, Puumala SE. Racial disparities in ordering laboratory and radiology tests for pediatric patients in the emergency department. Pediatr Emerg Care 2013; 29:598-606. [PMID: 23603649 DOI: 10.1097/pec.0b013e31828e6489] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to examine the association of race and language on laboratory and radiological testing in the pediatric emergency department (ED). METHODS This retrospective, case-cohort study examined laboratory and radiological testing among patients discharged home from 2 urban, pediatric EDs between March 2, 2009, and March 31, 2010. RESULTS There were 75,254 visits among 49,164 unique patients, of whom 31.0% had laboratory and 30.5% had radiological testing. African American (adjusted odds ratio [aOR], 0.93; confidence interval [CI], 0.89-0.98; P = 0.004) and biracial racial categories (aOR, 0.91; CI, 0.86-0.98; P = 0.007) were associated with decreased odds of laboratory testing compared with non-Hispanic whites. Similarly, Native American (aOR, 0.82; CI, 0.73-0.94), African American (aOR0.81; CI, 0.72-0.81), biracial (aOR, 0.82; CI, 0.77-0.88), Hispanic (aOR.76; CI, 0.72-0.81), and "other" (aOR, 0.84; CI, 0.73-0.97) racial categories were each associated with lower odds of radiological testing compared with non-Hispanic whites. Subgroup analysis of visits with a final diagnosis of fever and upper respiratory tract infection, conditions for which there were few treatment protocols, confirmed the racial differences. Subgroup analysis in visits for head injury, for which there is an established evaluation protocol, did not find a lower odds of laboratory or radiological testing by race compared with non-Hispanic whites. CONCLUSIONS Racial disparities in laboratory and radiological testing were present in pediatric ED visits. No racial differences were seen in the radiological and laboratory charges in the head injury subgroup, suggesting that evaluation algorithms can ameliorate racial disparities in pediatric ED care.
Collapse
Affiliation(s)
- Nathaniel R Payne
- Department of Quality, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN 55404, USA.
| | | |
Collapse
|