Frequent emergency department use in the paediatric population: A systematic literature review

Challenges and facilitators in child-friendly healthcare from the perspective of pediatric emergency nurses: A qualitative study

PURPOSE

This study aimed to determine pediatric emergency nurses' experiences and opinions regarding child-friendly care within Watson's Human Care Model framework.

DESIGN AND METHODS

This study is qualitative research conducted with nurses in the pediatric emergency unit of a university hospital between 06 March and 06 April 2024. This study used a purposive sampling method and conducted semi-structured interviews with 17 nurses. All interviews were audio recorded and transcribed. Inductive thematic analysis method was used. The study was written based on the COREQ checklist.

FINDINGS

This study determined two themes, five sub-themes, and 13 categories. The theme "challenges to child-friendly healthcare implementation" included a lack of physical space and agitated and violent families. It has been reported that physical space, especially where privacy is not protected, makes child-friendly care complex, and the violent reactions of families are significant obstacles. The second theme, "facilitators for an ideal child-friendly pediatric emergency unit," included the design of the pediatric emergency unit/improving physical environment, availability of appropriate equipment, and effective communication strategies. This theme emphasizes the importance of colorfully designing the physical space and equipment in a way that does not scare children.

CONCLUSION

It has been determined that the healing environment and care processes are essential for child-friendly care. During the care processes, communication according to the age of the children and communication with agitated families was emphasized as an essential component of care.

PRACTICE IMPLICATIONS

The study results will guide hospital management, healthcare professionals working in the field, and future studies on designing the child-friendly emergency unit that children deserve.

Role of primary care in enhancing continuity of care for adolescents and young adults with chronic kidney disease undergoing transition to adult health services

The transition from pediatric to adult health care is a vulnerable period for adolescents and young adults (AYA) with chronic conditions as it involves a multitude of changes and challenges while they enter adulthood. The transition to adult care can be particularly challenging for AYA living with chronic kidney disease (CKD) due to the complex care needed for treatment. Continuity of care is crucial for a successful transition to adult health care. The aim of this educational review is to discuss the potential role of primary care providers in the transition from pediatric to adult health services for AYA with CKD and kidney failure treated with dialysis and/or transplant. We address the significance of the medical home model and how it can provide continuity of care for AYA with CKD. Primary care providers can enhance care for AYA with chronic conditions by providing continuity of care, reducing exacerbation of chronic health conditions, providing holistic care, and fostering collaboration with specialists. Despite their vital role, primary care providers face barriers in maintaining this continuity, necessitating further attention and support in this area. By addressing these barriers and encouraging primary care providers to work alongside pediatric and adult nephrologists during the transition to adult health care, there are significant opportunities to improve the care and health outcomes of AYA with CKD.

Determinants of Persistent, Multi-Year, Frequent Emergency Department Use Among Children and Young Adults in Three US States

OBJECTIVE

This study examines the factors associated with persistent, multi-year, and frequent emergency department (ED) use among children and young adults.

METHODS

We conducted a retrospective secondary analysis using the 2012-2017 Healthcare Cost and Utilization Project State Emergency Department Databases for children and young adults aged 0-19 who visited any ED in Florida, Massachusetts, and New York. We estimated the association between persistent frequent ED use and individuals' characteristics using multivariable logistic regression models.

RESULTS

Among 1.3 million patients with 1.8 million ED visits in 2012, 2.9% (37,558) exhibited frequent ED use (≥4 visits in 2012) and accounted for 10.2% (181,138) of all ED visits. Longitudinal follow-up of frequent ED users indicated that 15.4% (5770) remained frequent users periodically over the next 1 or 2 years, while 2.2% (831) exhibited persistent frequent use over the next 3-5 years. Over the 6-year study period, persistent frequent users had 31,551 ED visits at an average of 38.0 (standard deviation = 16.2) visits. Persistent frequent ED use was associated with higher intensity of ED use in 2012, public health insurance coverage, inconsistent health insurance coverage over time, residence in non-metropolitan and lower-income areas, multimorbidity, and more ED visits for less medically urgent conditions.

CONCLUSIONS

Clinicians and policymakers should consider the diverse characteristics and needs of pediatric persistent frequent ED users compared to broader definitions of frequent users when designing and implementing interventions to improve health outcomes and contain ED visit costs.

Nurses' perspectives on child-friendly care needs in emergency departments: A qualitative study

BACKGROUND

Children can become anxious when undergoing emergency medical treatment. Therefore, emergency departments should be child friendly. This study explored emergency nurses' perspectives on children's needs during emergency care.

METHOD

This qualitative study employed purposive sampling to recruit 17 emergency nurses from 3 medical centers in northern and central Taiwan. Individual interviews were conducted between January and August 2021. Data were analyzed through qualitative content analysis.

RESULTS

The participants had 2-23 years of experience in caring for children in emergency departments. We identified 208 unique meaning units in the interview data, 79 of which were related to child-friendly emergency care. These were classified into 42 codes across 6 categories and 27 subcategories. The six categories were timely comfort, emotional care, frontline safety, emergency response, human resources support, and treatment efficiency.

CONCLUSION

Emergency nurses have professional competencies, play a crucial role as care providers for children in the emergency department, and ensure the comfort and safety of children seeking treatment. The categories related to child-friendly emergency care identified in this study can serve as a basis for developing child-friendly care emergency guidelines.

Factor structure and validity of the Parental Competence Questionnaire in the Paediatric Hospital Emergency Setting (ECP-U)

OBJECTIVE

To confirm the structure and examine the psychometric properties of the Parental Competence Questionnaire in the Paediatric Hospital Emergency Setting (ECP-U).

METHODS

An instrumental validation study of the ECP-U questionnaire and an examination of its psychometric properties were carried out.

RESULTS

The participants were 260 mothers and fathers seeking care in the paediatric emergency department of a hospital in Valencia (Spain) with children aged 0 to 14 years old. The five-factor structure of the ECP-U was confirmed with excellent statistical fits. Second-order models and a more parsimonious four-factor structure with adequate but marginal fits are proposed. With the exception of the "parental agency" factor (in both models examined) and the "active social support" factor (in the original five-factor structure), the internal consistency of the different factors was modest (≥ 0.70). A negative correlation was found between the Parental Stress Scale and the ECP-U for most factors.

CONCLUSIONS

Validity and reliability analyses indicate that the ECP-U is an instrument with modest psychometric properties.

IMPLICATIONS FOR PRACTICE

The ECP-U is an instrument that can be used by future researchers to identify different levels of parental competence in paediatric hospital emergency departments. This will enable help to be given to families with parenting issues and problems. The underlying concern is to reduce the number of frequent users and "Non-Urgent Presentations" to paediatric emergency departments due to low parental competence.

The Affordable Care Act and child asthma: Lowering health care barriers by raising our voices

BACKGROUND

This policy discussion addresses the provisions of the Affordable Care Act (ACA) that impact children with asthma.

PURPOSE

The purpose of this policy paper is to inform health care professionals and lawmakers about ACA provisions affecting pediatric asthma care and provide recommendations for policy changes that can improve equitable care for children with asthma.

METHODS

The issues addressed involve discrimination, Medicaid policy oversight, quality improvement stategy, data collection, school-based health care funding, accountable care organization reimbursement, and the extension of dependent coverage.

DISCUSSION

Health care policy development that focuses on human rights, and not market valuation, could reduce health inequity among children with asthma.

CONCLUSION

Policy recommendations are presented to improve asthma care for a population that is largely vulnerable due to age, socioeconomic status, and discrimination.

Paediatric frequent use of emergency medical services: a systematic review

BACKGROUND

Frequent use of emergency medical services (EMS) is recognised to be a global phenomenon, although paediatric frequent use is poorly understood. This systematic review aimed to understand how paediatric frequent use of EMS is currently defined, identify factors associated with paediatric frequent use of EMS and determine effectiveness of interventions for paediatric patients who frequently use EMS.

METHODS

Four electronic databases (Medline, CINAHL, Web of Science and PsycINFO) were searched to September 2022 for primary, peer-reviewed research studies published in English from January 2000. Studies were included that examined frequent use (>1 contact during study period) of EMS or other services with arrival via EMS. Paediatric patients were defined as <18 years of age or otherwise defined by study authors as paediatric/adolescent/children. Data were extracted using a structured proforma, and quality was assessed using the Standard Quality Assessment Criteria for Quantitative Studies but did not influence inclusion decisions. Data were presented using narrative synthesis.

RESULTS

The search resulted in 4172 unique references, with 12 papers included in the review from 7 countries. Four were EMS studies, and eight Emergency Department with arrival via EMS. All studies used retrospective designs, with no interventional studies identified. Paediatric frequent EMS users were more likely to use services for medical reasons rather than trauma, including respiratory complaints, mental health and seizures, but data on gender and ethnicity were inconclusive and silent on socioeconomic status. There was no consistency in definitions of either a paediatric patient or of frequent use.

CONCLUSION

The broad range of reasons for frequent use suggests that a single intervention is unlikely to be effective at addressing the causes of frequent use. There is a need for further research to better identify the underlying reasons for frequent EMS use among paediatric patients and to develop interventions in this population.

Effect of illuminated musical mobile on sleep quality of children hospitalized in pediatric emergency departments

PURPOSE

The aim of this study is to evaluate the effect of an illuminated musical mobile on the sleep quality of children hospitalized in a pediatric emergency department.

DESIGN AND METHODS

In this randomized controlled study, 124 children presenting to a pediatric emergency department who met the inclusion criteria were included in the study. Patients were randomized into two equal groups. In the intervention group, an illuminated musical mobile was used to help facilitate sleep. In the control group, routine sleep routines were continued. Groups were compared according to sleep quality as evaluated by mothers' observations. Evaluation was performed twice (before intervention - 1st day of hospitalization and on the intervention day - 2nd day of hospitalization).

RESULTS

Average age of children was 1.86 ± 0.78 years. On the intervention day, nighttime sleep duration was longer in the intervention group (p < .0001). Also, the frequency of spontaneous awakening (p < .0001), time to fall asleep after spontaneous awakening (p < .0001) and sleep time problems (p < .0001) were less in the intervention group. CONCLUSıONS: An illuminated musical mobile was used for the first time in the pediatric emergency department and was found to be effective in improving the sleep quality of hospitalized children aged between 1 and 3 years.

PRACTICE IMPLICATIONS

During hospitalization, children's sleep quality can be increased by using methods and objects suitable for the child's developmental level.

Describing the Patient Population of a Pediatric Emergency Department Based on Visit Frequency

OBJECTIVE

A small number of children in the United States use a disproportionate share of emergency healthcare services. Our study objective was to examine characteristics associated with frequent pediatric emergency department (PED) utilization.

METHODS

A retrospective cohort-sequential study of patients seen in the PED of an urban children's hospital was conducted. Patients were categorized into 2 groups: infrequent users (<4 visits during index year 2017) and frequent users (≥4 visits in 2017). Frequent PED users were further divided into persistent frequent (≥4 visits in the year before and after 2017) and incidental frequent (≥4 visits in 2017). Patient- and visit-level characteristics were analyzed for associations with PED utilization.

RESULTS

In 2017, there were 82,361 visits by 56,767 patients to our PED. Frequent users comprised 4% of the total patient volume but accounted for 13% of visits. Compared with infrequent users, frequent users were younger, more likely publicly insured, and English speaking. Frequent user visits were more likely to occur outside clinic hours, be triaged as emergent, and involve subspecialists. Compared with visits by incidental frequent users, visits by persistent frequent users were more likely to be emergent or urgent, and involve subspecialists, diagnostic imaging, laboratory testing, and medication administration.

CONCLUSIONS

Although the percentage of frequent users to a PED in 2017 was low, they made up a disproportionate share of total visits. Differences between persistent and incidental frequent PED users suggest that these subgroups may benefit from tailored interventions to reduce frequent PED utilization.

Expansion of primary healthcare and emergency hospital admissions among the urban poor in Rio de Janeiro Brazil: A cohort analysis

Background

Robust evidence on the relationship between primary care and emergency admissions is lacking in low- and middle-income countries. This study evaluates how the phased roll out of the family health strategy (FHS) to the urban poor in Rio de Janeiro Brazil affected emergency hospital admissions and readmissions from ambulatory-care sensitives conditions (ACSCs).

Methods

A cohort of 1.2 million adults in Rio de Janeiro city were followed for five years (Jan 2012 to Dec 2016). The association between FHS use and the likelihood of emergency hospital admissions and 30-day readmissions were evaluated using multi-level Poisson regression models with inverse probability treatment weighting and regression adjustment (IPTW-RA) for socioeconomic and household characteristics. Inequalities in associations were examined across groups of causes and by key socioeconomic groups.

Results

Records from 2,551,934 primary care consultations and 15,627 admissions were analysed. In IPTW-RA analyses, each additional FHS consultation was associated with a 3% lower rate of ACSC admission (RR: 0.97; 95%CI: 0.95, 0.98), a 63% lower rate of 30-day readmissions from any non-birth cause (RR: 0.37; 95%CI: 0.30, 0.46), and an 57% lower rate of 30-day readmissions from ACSCs (RR: 0.43; 95%CI: 0.33, 0.55). Individuals who were older, had the lowest educational attainment, were unemployed, and had higher incomes had larger reductions in ACSC admissions associated with FHS use.

Interpretation

Investment in primary care is important for reducing emergency hospital admissions and their associated costs in LMICs.

Funding

DFID/MRC/Wellcome Trust/ESRC.

Predictors of Pediatric Frequent Emergency Department Use Among 7.6 million Pediatric Patients in New York

OBJECTIVE

This study examines the characteristics and factors associated with frequent emergency department (ED) utilization among the pediatric population.

METHODS

We conducted a pooled cross-sectional secondary analysis using the Healthcare Cost and Utilization Project State Emergency and Inpatient Databases on ED visits to all hospitals in New York from 2011 to 2016 by patients aged 0 to 21. We used multivariable logistic and negative binomial regressions to investigate the predictors of multiple ED visits in the pediatric population.

RESULTS

Overall, our study included 7.6 million pediatric patients who accounted for more than 12 million ED visits. Of those, 6.2% of patients were frequent ED users (≥4 visits/year), accounting for 20.8% of all ED visits (5.4 ED visits/year on average). The strongest predictors of frequent ED use were having at least one ED visit related to asthma (aOR = 8.37 [95% CI: 6.34-11.04]), mental health disorders (aOR = 9.67 [95% CI: 8.60-10.89]), or multiple comorbidities compared to none. Larger shares of ED visits for not-emergent conditions were also associated with frequent ED use (aOR = 6.63 [95% CI = 5.08-8.65]). Being covered by Medicaid compared to private (aOR = 0.45 [95% CI: 0.42-0.47]) or no insurance (aOR = 0.41 [95% CI: 0.38-0.44]) were further associated with frequent ED use. The results from the negative binomial regression yielded consistent findings.

CONCLUSIONS

Pediatric patients who exhibit increased ED use are more medically complex and have increased healthcare needs that are inextricably tied to social determinants of health. Better integrated health systems should emphasize connecting vulnerable patients to appropriate social and primary care services outside of emergency settings.

Age-varying effects of repeated emergency department presentations for children in Canada

Objectives

Repeated presentations to emergency departments (EDs) may indicate a lack of access to other health care resources. Age is an important predictor of frequent ED use; however, age-varying effects are not generally investigated. This study examines the age-specific effects of predictors on ED presentation frequency for children in Alberta and Ontario, Canada.

Methods

This retrospective study used population-based data during April 2010 to March 2017. Data were extracted from the National Ambulatory Care Reporting System for children aged <18 who were members of the top 10% of ED users in any one of the fiscal years 2011/2012 to 2015/2016 along with a comparison sample from the bottom 90%. A marginal regression model studied the age-varying associations on the frequency of ED presentations with province, sex, access to primary health care provider (for Ontario only), area of residence and lowest neighbourhood income quintile.

Results

There were 2,481,172 patients who made 9,229,156 ED presentations. The effects of sex, lowest income quintile, rural residence, access to primary health care provider and province on the frequency of presentations varied by age. Notably, boys go from having more frequent presentations than girls when aged ≤5 (i.e. adjusted intensity ratio [IR]=1.04 at age 5, 95% confidence interval [CI] = 1.03,1.06) to less frequent for ages 8–11 years and beyond 14 (i.e. IR = 0.80 at age 15, 95% CI = 0.78,0.81). Adolescents aged ≥15 without access to a primary care provider had more frequent presentations compared to those with a primary care provider.

Conclusions

When examining the frequency of ED presentations in children, age-varying effects of predictors should be considered. Our more nuanced examination of age provides insights into how health services might better target programmes for different ages to potentially reduce unnecessary ED use by providing other health care alternatives.

Association of County-Level Availability of Pediatricians With Emergency Department Visits

OBJECTIVES

The relationship between pediatrician availability and emergency department (ED) attendance is uncertain. We determined whether children in counties with more pediatricians had fewer ED visits.

METHODS

We conducted a cross-sectional study of all ED visits among children younger than 18 years from 6 states. We obtained ED visit incidences by county and assessed the relationship to pediatrician density (pediatricians per 1000 children). Possible confounders included state, presence of an urgent care facility in the county, urban-rural status, and quartile of county-level characteristics: English-speaking, Internet access, White race, socioeconomic status, and public insurance. We estimated county-level changes in incidence by pediatrician density adjusting for state and separately for all possible confounders.

RESULTS

Each additional pediatrician per 1000 children was associated with a 13.7% (95% confidence interval, -19.6% to -7.5%) decrease in ED visits in the state-adjusted model. In the full model, there was no association (-1.4%, 95% confidence interval, -7.2% to 4.8%). The presence of an urgent care, higher socioeconomic status score, urban status, and higher proportions of White race and nonpublic insurance were each associated with decreased ED visit rates.

CONCLUSIONS

Pediatrician density is not associated with decreased ED visits after adjusting for other county demographic factors. Increasing an area's availability of pediatricians may not affect ED attendance.

Social Determinants of Health Needs and Pediatric Health Care Use

OBJECTIVE

To examine the associations between family-reported social needs in primary care settings and pediatric health care use.

STUDY DESIGN

Data were obtained for a sample of 56 253 children and youths (age 0-21 years) who received primary care at a large hospital-based pediatric institution between June 2018 and October 2019 to estimate a propensity score for the probability of being seen in a primary care clinic. Inverse probability weighted regression specifications were used to examine the associations between reported social needs and health care use. Families were asked about 4 social needs: housing, utilities, transportation, and food. Outcomes included the number of Emergency Department (ED), inpatient, social work, and well-child visits (only for those aged 0-2 years) in the 6 months before and after needs screening.

RESULTS

Overall, 12.0% of the families reported a general social need, with 28% of those needs identified as urgent. Food and transportation needs were most common. Patients with needs were more likely to have an ED or inpatient visit at 6 months prescreening and 6 months postscreening compared with those without needs. Among children aged <2 years, those with a social need were less likely to have completed a well-child visit at 6 months postscreening compared with those without a need.

CONCLUSIONS

Social needs are linked to less preventive care use and greater reliance on emergency care services. Understanding how to better assist families in need requires greater attention.

Health insurance, pediatric asthma, and emergency department usage

This study synthesized current research on the relationships between type of insurance and emergency department usage for children with asthma in the United States. Thematic analysis is in the context of the Affordable Care Act (ACA). A systematic mapping review yielded 20 articles published in the last 10 years on topics of insurance, emergency department usage, and pediatric asthma. Analysis indicates continued trends of increased emergency department use among asthmatic children since enactment of the ACA, running counter to the goal of fiscal efficiency for the healthcare system and reduction of health inequities. Barriers to care persist, particularly among communities of color, despite provisions to improve access to primary and preventive care. Inadequate access to primary care is associated with poor adherence among asthmatic children with public insurance. Those with health insurance through their parents' employer experience barriers due to cost-sharing expenses. This leads to increased asthma severity and low medication adherence, resulting in the need for emergency care. A disconnect between increased health insurance coverage and utilization of primary care in some populations implies unmet service needs that warrant further investigation. Findings inform policymakers and public health leaders of persistent health inequities resulting in preventable emergency department usage.

Pediatric high users of Canadian hospitals and emergency departments

INTRODUCTION

Few studies have examined the most frequent pediatric users of hospital services. Our objective was to determine the clinical diagnoses, demographic characteristics, and medical severity of high-use pediatric patients in Canada.

METHODS

We conducted a retrospective analysis of patients <18 years of age who either were admitted to hospital or visited an emergency department (ED) using the Canadian Institute for Health Information's (CIHI) Dynamic Cohort of Complex, High System Users. The analysis of hospital admission data excluded Quebec and Manitoba. ED data was only available for Alberta and Ontario.

RESULTS

121 104 patients were identified as the most frequent hospital users and 459 998 patients as the most frequent ED users. High users were more likely to reside in a rural community, to be in a lower income quintile, and face more deprivation. The most frequent conditions for hospitalization for high use patients were disorders related to length of prematurity and fetal growth, respiratory and cardiovascular disorders specific to the perinatal period, and haemorrhagic and haematological disorders of fetus and newborn. For the most frequent ED users, the most common clinical diagnoses were acute upper respiratory infections, injuries to the head, and diseases of the middle ear and mastoid.

CONCLUSION

Pediatric high users by frequency of hospital and ED services are a distinct population. Better understanding their characteristics will allow for more appropriate planning of children's health services and help identify areas for effective preventive or quality improvement initiatives.