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Akcan Yildiz L, Akca H, Kurt F, Hanalioglu D, Cetin M, Senel S, Karacan CD. Improving croup management at a pediatric emergency department. Postgrad Med 2024; 136:438-445. [PMID: 38804969 DOI: 10.1080/00325481.2024.2360889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 05/23/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVES Over-testing and over-treatment are common in children with croup at pediatric emergency departments (PED). The objective of the study was to improve care for children with croup. METHODS In this quality improvement (QI) initiative, all pediatric residents starting their rotation in the PED attended an informative presentation about croup and were provided reminders throughout their rotation. The primary outcome of this QI initiative was to reduce nebulized epinephrine (NE) use among children with mild croup by 50% over 7 months. The secondary outcome was to reduce X-rays by 50% over 7 months. Other outcomes included the administration of dexamethasone to all children with croup, reduction of antibiotics, laboratory tests, and revisits, and shortening the duration between physical examination to dexamethasone and NE treatments, and the length of stay (LOS) at the PED. RESULTS NE administration to patients with mild croup decreased from 80.2% to 36.3% (p < 0.001). The proportion of children with X-rays decreased from 37.4% to 17.1% (p < 0.001). There was a significant increase in dexamethasone administration, and significant decreases in laboratory blood tests, expanded viral PCR panel tests, and antibiotic prescription among all croup cases (p < 0.001). Revisit rates were not significantly different (p > 0.05). Time to dexamethasone and LOS shortened significantly (p < 0.001). CONCLUSION With this QI intervention, decreases in the rate of administration of NE to mild croup cases, antibiotic prescription, X-ray, laboratory blood and respiratory PCR panel tests in all croup cases were achieved without an increase in revisits. However, unnecessary NE, antibiotic, and X-ray rates are still high.
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Affiliation(s)
- Leman Akcan Yildiz
- Pediatric Emergency Clinic, Ankara Bilkent City Hospital, Ankara, Türkiye
| | - Halise Akca
- Pediatric Emergency Clinic, Ankara Bilkent City Hospital, Ankara, Türkiye
- Pediatric Emergency Department, Ankara Yildirim Beyazit University, Ankara, Türkiye
| | - Funda Kurt
- Pediatric Emergency Clinic, Ankara Bilkent City Hospital, Ankara, Türkiye
- Pediatric Emergency Department, University of Health Sciences, Ankara, Türkiye
| | - Damla Hanalioglu
- Pediatric Emergency Clinic, Ankara Bilkent City Hospital, Ankara, Türkiye
| | - Meltem Cetin
- Pediatric Emergency Clinic, Ankara Bilkent City Hospital, Ankara, Türkiye
| | - Saliha Senel
- Pediatric Emergency Clinic, Ankara Bilkent City Hospital, Ankara, Türkiye
- Pediatric Emergency Department, Ankara Yildirim Beyazit University, Ankara, Türkiye
| | - Can Demir Karacan
- Pediatric Emergency Clinic, Ankara Bilkent City Hospital, Ankara, Türkiye
- Pediatric Emergency Department, Ankara Yildirim Beyazit University, Ankara, Türkiye
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Myers AL, Fussell JJ, Moffatt ME, Boyer D, Ross R, Dammann CEL, Degnon L, Weiss P, Sauer C, Vinci RJ. The Importance of Subspecialty Pediatricians to the Health and Wellbeing of the Nation's Children. J Pediatr 2023:13365. [PMID: 36894130 DOI: 10.1016/j.jpeds.2023.02.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 02/20/2023] [Indexed: 03/11/2023]
Abstract
Through this review of published literature, it is clear that children benefit in measurable ways when they receive care from trained pediatric subspecialists. The improved outcomes provided by pediatric subspecialists supports the care provided in the patient's pediatric medical home and emphasizes the importance of care coordination between all components of the pediatric workforce. The AAP highlights this in a recent policy statement by stating the care provided by pediatric clinicians "encompasses diagnosis and treatment of acute and chronic health disorders; management of serious and life-threatening illnesses; and when appropriate, referral of patients with more complex conditions for medical subspecialty or surgical specialty care" Explicit in this statement is the emphasis on the role of complex care coordination between pediatric specialist and primary care pediatricians and that collaboration and guidance by the pediatrician is central to providing optimal care of patients. 65 Improving health outcomes early in life is an important public health strategy for modifying the complications from childhood chronic disease and highlights the role of pediatricians in mitigating the long-term consequences of antecedents of adult disease. 66 The recent announcement of the National Academies of Science, Engineering, and Medicine (NASEM)'s plan for a Consensus Study on The Pediatric Subspecialty Workforce and Its Impact on Child Health and Well-being is a related and exciting development, on a national scale. 67 In response to shortages and geographic maldistributions of pediatric subspecialists, the NASEM committee intends to assess the impact of current pediatric clinical workforce trends on child health and well-being, in order to develop informed strategies to ensure an adequate, high-quality pediatric workforce, with a robust research portfolio that informs those recommendations. While this large, national initiative will surely lead to a better understanding of and strategies to implement across the pediatric subspecialty workforce, more well-designed studies that specifically measure child outcomes related to access to pediatric subspecialty care, would add meaningfully to the body of pediatric literature and to our national pediatric advocacy initiatives.
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Affiliation(s)
- Angela L Myers
- Professor of Pediatrics, Children's Mercy, Kansas City, University of Missouri-Kansas City, KC, MO
| | - Jill J Fussell
- Professor, University of Arkansas for Medical Sciences/Arkansas Children's Hospital, Little Rock, AR
| | - Mary E Moffatt
- Professor of Pediatrics, Children's Mercy, Kansas City, University of Missouri-Kansas City, KC, MO
| | - Debra Boyer
- DIO/Chief Medical Education Officer, Professor of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Robert Ross
- Children's Hospital of Michigan, Professor of Pediatrics, Central Michigan University College of Medicine, Detroit, MI
| | | | | | - Pnina Weiss
- Professor of Pediatrics, Yale School of Medicine, New Haven, CT
| | - Cary Sauer
- Professor of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Robert J Vinci
- Professor of Pediatrics, Boston University School of Medicine, Boston, MA
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Freire GC, Diong C, Gandhi S, Saunders N, Neuman MI, Freedman SB, Friedman JN, Cohen E. Variation in low-value radiograph use for children in the emergency department: a cross-sectional study of administrative databases. CMAJ Open 2022; 10:E889-E899. [PMID: 36220182 PMCID: PMC9578750 DOI: 10.9778/cmajo.20210140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Radiograph use contributes to low-value care for children in emergency departments (EDs), but little is known about systemic factors associated with their use. This study compares low-value radiograph use across ED settings by hospital type, pediatric volumes and physician specialty. METHODS This is a cross-sectional study of routinely collected administrative data. We included children (age 0-18 yr) discharged from EDs in Ontario, Canada, between 2010 and 2019 with diagnoses of bronchiolitis, asthma, abdominal pain and constipation. Multiple clinical practice guidelines recommend against routine radiograph use in these conditions. Logistic regression evaluated odds of low-value radiograph by ED setting (pediatric academic [referent], adult academic, community with or without pediatric consultation services), pediatric volume and physician specialty (pediatric emergency medicine [PEM, referent], emergency medicine [EM], family medicine with EM training, pediatrics, family medicine), adjusting for demographic, clinical and provider characteristics. We used generalized estimating equations to account for clustering by ED. RESULTS Of the total 9 862 787 eligible pediatric ED discharges in Ontario, 60 914 children had bronchiolitis, 141 921 asthma, 333 332 abdominal pain and 110 514 constipation; 26.0% received low-value radiographs. Compared with pediatric EDs and PEM physicians (referents), patients with bronchiolitis were most likely to have a chest radiograph in adult academic EDs (adjusted odds ratio [OR] 5.1 [95% confidence interval (CI) 4.6-5.6]) and by family physicians with EM training (adjusted OR 4.8 [95% CI 4.5-5.1]). Patients with asthma were more likely to have a chest radiograph in adult academic EDs (adjusted OR 3.0 [95% CI 2.8-3.2]) and by EM physicians (adjusted OR 2.8 [95% CI 2.6-3.0]). Patients with abdominal pain and constipation were more likely to have abdominal radiographs in community hospitals with pediatric consultation (adjusted OR 1.6 [95% CI 1.6-1.7] and 2.3 [95% CI 2.3-2.4], respectively) and by family physicians with EM training (adjusted OR 1.6 [95% CI 1.6-1.7] and 2.1 [95% CI 2.0-2.2], respectively). INTERPRETATION Over the decade-long study period, low-value radiograph use was frequent for children with 4 common conditions seen in Ontario EDs. Quality improvement initiatives aimed at reducing unnecessary radiographs in children should focus on EM physicians practising in EDs that primarily treat adult patients.
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Affiliation(s)
- Gabrielle C Freire
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Christina Diong
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Sima Gandhi
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Natasha Saunders
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Mark I Neuman
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Stephen B Freedman
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Jeremy N Friedman
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Eyal Cohen
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta.
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Abstract
OBJECTIVES The aims of the study were to estimate testing and treatment rates among pediatric low-acuity emergency department (ED) visits and to compare testing and treatment patterns at general and pediatric-specific EDs. METHODS We performed a cross-sectional study of triage level 4 or 5 pediatric visits from a complex survey of nonfederal US EDs from 2008 to 2017. We analyzed demographics, vital signs, disposition, testing, and treatment. We calculated proportions for each data element and used χ2 tests to determine differences between general and pediatric EDs. RESULTS There were an estimated 306.2 million pediatric visits with 129.1 million acuity level 4 or 5 visits (57.2%; 95% confidence interval, 55.4%-58.9%), with diagnostic testing performed in 47.1% and medications administered in 69.6% of the visits. Most low-acuity visits (82.0%) were to general EDs. Tests performed more frequently in general EDs compared with pediatric EDs included radiographs (25.8% vs 15.7%, P < 0.01), complete blood count (6.4% vs 3.9%, P < 0.01), electrolytes (11.6% vs 3.7%, P < 0.01), and glucose (2.0% vs 0.9%, P < 0.01). Ultrasound was used less frequently in general EDs (0.5 vs 0.7, P < 0.01). There were similar rates of intravenous fluid and overall medication administration and a higher proportion of patients receiving antibiotics in general EDs (28.7% vs 23.8%, P < 0.01). CONCLUSIONS More than half of pediatric visits to the ED are low acuity. Although general EDs relied on more imaging, blood testing and antibiotics, and pediatric EDs on ultrasound, overall resource utilization was high in this population across both ED types and can likely be reduced.
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Affiliation(s)
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jennifer R Marin
- Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
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Hudgins JD, Neuman MI, Monuteaux MC, Porter J, Nelson KA. Provision of Guideline-Based Pediatric Asthma Care in US Emergency Departments. Pediatr Emerg Care 2021; 37:507-512. [PMID: 30624420 DOI: 10.1097/pec.0000000000001706] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES National guidelines for routine pediatric acute asthma care recommend providing corticosteroids, and discourage routinely obtaining chest radiographs (CXRs) and using antibiotics. We examined rates of adherence to all 3 of these aspects during emergency department (ED) visits and compared performance between pediatric and general EDs. METHODS Using the National Hospital Ambulatory Medical Care Survey, we included all nontransfer ED visits for patients younger than 19 years with a diagnosis of asthma and treatment with albuterol from 2005 to 2015. Guideline-based care, defined as (1) corticosteroids, (2) no antibiotics, and (3) no CXR, was assessed for each visit. Hospitals were categorized as pediatric or general and compared according to rates of guideline-based care. Multivariable analyses were used to identify demographic and hospital-level characteristics associated with guideline-based care. RESULTS More than 7 million ED visits met eligibility criteria. Antibiotic provision and CXR acquisition were significantly higher in general EDs (20% vs 11%, 40% vs 26%, respectively), while steroid provision was similar (63% vs 62%). Overall, 34% of visits involved guideline-based care, with a higher rate for pediatric EDs compared with general EDs (42% to 31%). Visit at a pediatric ED (odds ratio, 1.62 [confidence interval 1.17-2.25]) and black race (odds ratio, 1.48 [confidence interval 1.07-2.02]) were independently associated with guideline-based care in a multivariate analysis. CONCLUSIONS Guideline-based care was more common in pediatric EDs, although only one-third of all pediatric-age visits met the definition of guideline-based care. Future policy and education efforts to reduce unnecessary antibiotic and CXR use for children with asthma are warranted.
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Affiliation(s)
- Joel D Hudgins
- From the Division of Emergency Medicine, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, MA
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Patel NH, Hassoun A, Chao JH. The Practice of Obtaining a Chest Radiograph in Pediatric Patients Presenting With Their First Episode of Wheezing: A Survey of Resident Physicians. Clin Pediatr (Phila) 2021; 60:465-473. [PMID: 34486411 DOI: 10.1177/00099228211044296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A chest radiograph (CXR) is not routinely indicated in children presenting with their first episode of wheezing; however, it continues to be overused. A survey was distributed electronically to determine what trainees are taught and their current practice of obtaining a CXR in children presenting with their first episode of wheezing and the factors that influence this practice. Of the 1513 trainees who completed surveys, 35.3% (535/1513) reported that they were taught that pediatric patients presenting with their first episode of wheezing should be evaluated with a CXR. In all, 22.01% (333/1513) indicated that they would always obtain a CXR in these patients, and 13.75% (208/1513) would always obtain a CXR under a certain age (4 weeks to 12 years, median of 2 years). Our study identifies a target audience that would benefit from education to decrease the overuse of CXRs in children.
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Affiliation(s)
| | - Ameer Hassoun
- New York Presbyterian-Queens Hospital, Flushing, NY, USA
| | - Jennifer H Chao
- SUNY Downstate Medical Center/Kings County Hospital Center, Brooklyn, NY, USA
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Wolf ER, Richards A, Lavallee M, Sabo RT, Schroeder AR, Schefft M, Krist AH. Patient, Provider, and Health Care System Characteristics Associated With Overuse in Bronchiolitis. Pediatrics 2021; 148:peds.2021-051345. [PMID: 34556548 PMCID: PMC8830481 DOI: 10.1542/peds.2021-051345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The American Academy of Pediatrics recommends against the routine use of β-agonists, corticosteroids, antibiotics, chest radiographs, and viral testing in bronchiolitis, but use of these modalities continues. Our objective for this study was to determine the patient, provider, and health care system characteristics that are associated with receipt of low-value services. METHODS Using the Virginia All-Payers Claims Database, we conducted a retrospective cross-sectional study of children aged 0 to 23 months with bronchiolitis (code J21, International Classification of Diseases, 10th Revision) in 2018. We recorded medications within 3 days and chest radiography or viral testing within 1 day of diagnosis. Using Poisson regression, we identified characteristics associated with each type of overuse. RESULTS Fifty-six percent of children with bronchiolitis received ≥1 form of overuse, including 9% corticosteroids, 17% antibiotics, 20% β-agonists, 26% respiratory syncytial virus testing, and 18% chest radiographs. Commercially insured children were more likely than publicly insured children to receive a low-value service (adjusted prevalence ratio [aPR] 1.21; 95% confidence interval [CI]: 1.15-1.30; P < .0001). Children in emergency settings were more likely to receive a low-value service (aPR 1.24; 95% CI: 1.15-1.33; P < .0001) compared with children in inpatient settings. Children seen in rural locations were more likely than children seen in cities to receive a low-value service (aPR 1.19; 95% CI: 1.11-1.29; P < .0001). CONCLUSIONS Overuse in bronchiolitis remains common and occurs frequently in emergency and outpatient settings and rural locations. Quality improvement initiatives aimed at reducing overuse should include these clinical environments.
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Affiliation(s)
- Elizabeth R. Wolf
- Children’s Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia,Department of Pediatrics, Virginia Commonwealth University, Richmond, Virginia
| | - Alicia Richards
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia
| | - Martin Lavallee
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia
| | - Roy T. Sabo
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia
| | - Alan R. Schroeder
- Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, California
| | - Matthew Schefft
- Children’s Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia,Department of Pediatrics, Virginia Commonwealth University, Richmond, Virginia
| | - Alex H. Krist
- Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia
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Borensztajn D, Zachariasse JM, Greber-Platzer S, Alves CF, Freitas P, Smit FJ, van der Lei J, Steyerberg EW, Maconochie I, Moll HA. Shortness of breath in children at the emergency department: Variability in management in Europe. PLoS One 2021; 16:e0251046. [PMID: 33951099 PMCID: PMC8099081 DOI: 10.1371/journal.pone.0251046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 04/20/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Our aim was to describe variability in resource use and hospitalization in children presenting with shortness of breath to different European Emergency Departments (EDs) and to explore possible explanations for variability. DESIGN The TrIAGE project, a prospective observational study based on electronic health record data. PATIENTS AND SETTING Consecutive paediatric emergency department visits for shortness of breath in five European hospitals in four countries (Austria, Netherlands, Portugal, United Kingdom) during a study period of 9-36 months (2012-2014). MAIN OUTCOME MEASURES We assessed diversity between EDs regarding resource use (diagnostic tests, therapy) and hospital admission using multivariable logistic regression analyses adjusting for potential confounding variables. RESULTS In total, 13,552 children were included. Of those, 7,379 were categorized as immediate/very urgent, ranging from 13-80% in the participating hospitals. Laboratory tests and X-rays were performed in 8-33% of the cases and 21-61% was treated with inhalation medication. Admission rates varied between 8-47% and PICU admission rates varied between 0.1-9%. Patient characteristics and markers of disease severity (age, sex, comorbidity, urgency, vital signs) could explain part of the observed variability in resource use and hospitalization. However, after adjusting for these characteristics, we still observed substantial variability between settings. CONCLUSION European EDs differ substantially regarding the resource use and hospitalization in children with shortness of breath, even when adjusting for patient characteristics. Possible explanations for this variability might be unmeasured patient characteristics such as underlying disease, differences in guideline use and adherence or different local practice patterns.
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Affiliation(s)
- Dorine Borensztajn
- Department of General Paediatrics, Erasmus MC-Sophia Children’s Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
- * E-mail:
| | - Joany M. Zachariasse
- Department of General Paediatrics, Erasmus MC-Sophia Children’s Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Susanne Greber-Platzer
- Department of Paediatrics and Adolescent Medicine, Medical University Vienna, Vienna, Austria
| | - Claudio F. Alves
- Department of Paediatrics, Hospital Prof. Dr. Fernando da Fonseca, Lisbon, Portugal
| | - Paulo Freitas
- Intensive Care Unit, Hospital Prof. Dr. Fernando da Fonseca, Lisbon, Portugal
| | - Frank J. Smit
- Department of Paediatrics, Maasstad Hospital, Rotterdam, The Netherlands
| | - Johan van der Lei
- Department of Medical Informatics, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Ewout W. Steyerberg
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Ian Maconochie
- Department of Paediatric Accident and Emergency, Imperial College NHS Healthcare Trust, London, United Kingdom
| | - Henriëtte A. Moll
- Department of General Paediatrics, Erasmus MC-Sophia Children’s Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
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Markham JL, Hall M, Goldman JL, Bettenhausen JL, Gay JC, Feinstein J, Simmons J, Doupnik SK, Berry JG. Readmissions Following Hospitalization for Infection in Children With or Without Medical Complexity. J Hosp Med 2021; 16:134-141. [PMID: 33617439 PMCID: PMC7929613 DOI: 10.12788/jhm.3505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 07/13/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To describe the prevalence and characteristics of infection-related readmissions in children and to identify opportunities for readmission reduction and estimate associated cost savings. STUDY DESIGN Retrospective analysis of 380,067 nationally representative index hospitalizations for children using the 2014 Nationwide Readmissions Database. We compared 30-day, all-cause unplanned readmissions and costs across 22 infection categories. We used the Inpatient Essentials database to measure hospital-level readmission rates and to establish readmission benchmarks for individual infections. We then estimated the number of readmissions avoided and costs saved if hospitals achieved the 10th percentile of hospitals' readmission rates (ie, readmission benchmark). All analyses were stratified by the presence/absence of a complex chronic condition (CCC). RESULTS The overall 30-day readmission rate was 4.9%. Readmission rates varied substantially across infections and by presence/absence of a CCC (CCC: range, 0%-21.6%; no CCC: range, 1.5%-8.6%). Approximately 42.6% of readmissions (n = 3,576) for children with a CCC and 54.7% of readmissions (n = 5,507) for children without a CCC could have been potentially avoided if hospitals achieved infection-specific benchmark readmission rates, which could result in an estimated savings of $70.8 million and $44.5 million, respectively. Bronchiolitis, pneumonia, and upper respiratory tract infections were among infections with the greatest number of potentially avoidable readmissions and cost savings for children with and without a CCC. CONCLUSION Readmissions following hospitalizations for infection in children vary significantly by infection type. To improve hospital resource use for infections, future preventative measures may prioritize children with complex chronic conditions and those with specific diagnoses (eg, respiratory illnesses).
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Affiliation(s)
- Jessica L Markham
- Department of Pediatrics, Children’s Mercy Kansas City and the University of Missouri–Kansas City School of Medicine, Kansas City, Missouri
- Department of Pediatrics, University of Kansas School of Medicine, Kansas City, Kansas
- Corresponding Author: Jessica L Markham, MD, MSc; ; Telephone: 816-302-3493; Twitter: @jmarks614
| | - Matt Hall
- Department of Pediatrics, Children’s Mercy Kansas City and the University of Missouri–Kansas City School of Medicine, Kansas City, Missouri
- Children’s Hospital Association, Lenexa, Kansas
| | - Jennifer L Goldman
- Department of Pediatrics, Children’s Mercy Kansas City and the University of Missouri–Kansas City School of Medicine, Kansas City, Missouri
- Department of Pediatrics, University of Kansas School of Medicine, Kansas City, Kansas
| | - Jessica L Bettenhausen
- Department of Pediatrics, Children’s Mercy Kansas City and the University of Missouri–Kansas City School of Medicine, Kansas City, Missouri
- Department of Pediatrics, University of Kansas School of Medicine, Kansas City, Kansas
| | - James C Gay
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James Feinstein
- Department of Pediatrics, Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), Children’s Hospital Colorado, Aurora, Colorado
- Department of Pediatrics, University of Colorado School of Medicine at Denver, Aurora, Colorado
| | - Julia Simmons
- Department of Pediatrics, Children’s Mercy Kansas City and the University of Missouri–Kansas City School of Medicine, Kansas City, Missouri
- Department of Pediatrics, University of Kansas School of Medicine, Kansas City, Kansas
- Department of Pediatrics, Mercy Children’s Hospital St Louis, St Louis, Missouri
| | - Stephanie K Doupnik
- Division of General Pediatrics, PolicyLab, and Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jay G Berry
- Division of General Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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Martin-Harris B, Canon CL, Bonilha HS, Murray J, Davidson K, Lefton-Greif MA. Best Practices in Modified Barium Swallow Studies. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2020; 29:1078-1093. [PMID: 32650657 PMCID: PMC7844340 DOI: 10.1044/2020_ajslp-19-00189] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 04/01/2020] [Accepted: 04/11/2020] [Indexed: 05/22/2023]
Abstract
Purpose The modified barium swallow study (MBSS) is a widely used videofluoroscopic evaluation of the functional anatomy and physiology of swallowing that permits visualization of bolus flow throughout the upper aerodigestive tract in real time. The information gained from the examination is critical for identifying and distinguishing the type and severity of swallowing impairment, determining the safety of oral intake, testing the effect of evidence-based frontline interventions, and formulating oral intake recommendations and treatment planning. The goal of this review article is to provide the state of the science and best practices related to MBSS. Method State of the science and best practices for MBSS are reviewed from the perspectives of speech-language pathologists (SLPs) and radiologists who clinically practice and conduct research in this area. Current quandaries and emerging clinical and research trends are also considered. Results This document provides an overview of the MBSS and standards for conducting, interpreting, and reporting the exam; the SLPs' and radiologist's perspectives on standardization of the exam; radiation exposure; technical parameters for recording and reviewing the exam; the importance of an interdisciplinary approach with engaged radiologists and SLPs; and special considerations for examinations in children. Conclusions The MBSS is the primary swallowing examination that permits visualization of bolus flow and swallowing movement throughout the upper aerodigestive tract in real time. The clinical validity of the study has been established when conducted using reproducible and validated protocols and metrics applied according to best practices to provide accurate and reliable information necessary to direct treatment planning and limit radiation exposure. Standards and quandaries discussed in this review article, as well as references, provide a basis for understanding the current best practices for MBSS.
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Affiliation(s)
- Bonnie Martin-Harris
- Roxelyn and Richard Pepper Department of Communication Sciences and Disorders, Northwestern University, Evanston, IL
| | - Cheri L. Canon
- Department of Radiology, The University of Alabama at Birmingham School of Medicine
| | - Heather Shaw Bonilha
- Department of Health Science and Research, Medical University of South Carolina, Charleston
- Department of Otolaryngology—Head & Neck Surgery, Medical University of South Carolina, Charleston
| | - Joseph Murray
- Audiology and Speech-Language Pathology Service, VA Ann Arbor Healthcare System, MI
| | - Kate Davidson
- Department of Otolaryngology—Head & Neck Surgery, Medical University of South Carolina, Charleston
| | - Maureen A. Lefton-Greif
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
- Department of Otolaryngology—Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD
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11
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Zamor R, Byczkowski T, Zhang Y, Vaughn L, Mahabee-Gittens EM. Language Barriers and the Management of Bronchiolitis in a Pediatric Emergency Department. Acad Pediatr 2020; 20:356-363. [PMID: 31981655 PMCID: PMC7102638 DOI: 10.1016/j.acap.2020.01.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 01/14/2020] [Accepted: 01/18/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Language barriers may influence the management of pediatric emergency department (PED) patients who may not align with evidence-based guidelines from the American Academy of Pediatrics. Our objective was to determine if a family's preferred language of Spanish versus English was associated with differences in management of bronchiolitis in the PED. METHODS We conducted a retrospective study of children ≤2 years old diagnosed with bronchiolitis in a PED over a 7-year period. Rates of PED testing, interventions, and disposition among children whose families' preferred language was Spanish were compared to children whose families' preferred language was English. Primary outcomes were frequencies of chest x-ray and bronchodilator orders. Secondary outcomes were diagnostic testing, medication orders, and disposition. Logistic regression was used to calculate adjusted odds ratios after controlling for age, emergency severity index, prior visit, and nesting within attending physicians. RESULTS A total of 13,612 encounters were included. Spanish-speaking families were more likely to have chest x-rays (35.8% vs 26.7%, P < .0001; adjusted odds ratio [aOR] 1.5; 95% confidence interval [CI] 1.2-1.9), complete blood counts (8.2% vs 4.9%, P < .005; aOR 1.7; 95% CI 1.2-2.5), and blood cultures ordered (8.1% vs 5.0%, P < .05; aOR 1.7; 95% CI 1.2-2.4). No other differences in bronchodilators, medication orders, or disposition were found between the 2 groups. CONCLUSIONS Among children diagnosed with bronchiolitis, Spanish-speaking families were more likely to have chest x-rays, complete blood counts, and blood cultures ordered compared to English-speaking families. Further research on how clinical practice guidelines and equity-focused guidelines can impact disparities in diagnostic testing within the PED is warranted.
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Affiliation(s)
- Ronine Zamor
- Department of Emergency Medicine, Cincinnati Children's Hospital and Medical Center (R Zamor, T Byczkowski, L Vaughn, and EM Mahabee-Gittens), Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine (R Zamor, T Byczkowski, L Vaughn, and EM Mahabee-Gittens), Cincinnati, Ohio.
| | - Terri Byczkowski
- Department of Emergency Medicine, Cincinnati Children's Hospital and Medical Center (R Zamor, T Byczkowski, L Vaughn, and EM Mahabee-Gittens), Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine (R Zamor, T Byczkowski, L Vaughn, and EM Mahabee-Gittens), Cincinnati, Ohio
| | - Yin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center (Y Zhang), Cincinnati, Ohio
| | - Lisa Vaughn
- Department of Emergency Medicine, Cincinnati Children's Hospital and Medical Center (R Zamor, T Byczkowski, L Vaughn, and EM Mahabee-Gittens), Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine (R Zamor, T Byczkowski, L Vaughn, and EM Mahabee-Gittens), Cincinnati, Ohio
| | - E Melinda Mahabee-Gittens
- Department of Emergency Medicine, Cincinnati Children's Hospital and Medical Center (R Zamor, T Byczkowski, L Vaughn, and EM Mahabee-Gittens), Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine (R Zamor, T Byczkowski, L Vaughn, and EM Mahabee-Gittens), Cincinnati, Ohio
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12
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Schinkelshoek G, Borensztajn DM, Zachariasse JM, Maconochie IK, Alves CF, Freitas P, Smit FJ, van der Lei J, Steyerberg EW, Greber-Platzer S, Moll HA. Management of children visiting the emergency department during out-of-office hours: an observational study. BMJ Paediatr Open 2020; 4:e000687. [PMID: 32984551 PMCID: PMC7493126 DOI: 10.1136/bmjpo-2020-000687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/11/2020] [Accepted: 06/12/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The aim was to study the characteristics and management of children visiting the emergency department (ED) during out-of-office hours. METHODS We analysed electronic health record data from 119 204 children visiting one of five EDs in four European countries. Patient characteristics and management (diagnostic tests, treatment, hospital admission and paediatric intensive care unit admission) were compared between children visiting during office hours and evening shifts, night shifts and weekend day shifts. Analyses were corrected for age, gender, Manchester Triage System urgency, abnormal vital signs, presenting problems and hospital. RESULTS Patients presenting at night were younger (median (IQR) age: 3.7 (1.4-8.2) years vs 4.8 (1.8-9.9)), more often classified as high urgent (16.3% vs 9.9%) and more often had ≥2 abnormal vital signs (22.8% vs 18.1%) compared with office hours. After correcting for disease severity, laboratory and radiological tests were less likely to be requested (adjusted OR (aOR): 0.82, 95% CI 0.78-0.86 and aOR: 0.64, 95% CI 0.60-0.67, respectively); treatment was more likely to be undertaken (aOR: 1.56, 95% CI 1.49-1.63) and patients were more likely to be admitted to the hospital (aOR: 1.32, 95% CI 1.24-1.41) at night. Patterns in management during out-of-office hours were comparable between the different hospitals, with variability remaining. CONCLUSIONS Children visiting during the night are relatively more seriously ill, highlighting the need to keep improving emergency care on a 24-hour-a-day basis. Further research is needed to explain the differences in management during the night and how these differences affect patient outcomes.
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Affiliation(s)
- Gina Schinkelshoek
- Department of General Paediatrics, Erasmus MC Sophia Children Hospital, Rotterdam, Zuid-Holland, The Netherlands
| | - Dorine M Borensztajn
- Department of General Paediatrics, Erasmus MC Sophia Children Hospital, Rotterdam, Zuid-Holland, The Netherlands
| | - Joany M Zachariasse
- Department of General Paediatrics, Erasmus MC Sophia Children Hospital, Rotterdam, Zuid-Holland, The Netherlands
| | - Ian K Maconochie
- Department of Paediatric Accident and Emergency, Imperial College Healthcare NHS Trust, London, UK
| | - Claudio F Alves
- Department of Paediatrics, Professor Doutor Fernando Fonseca Hospital, Amadora, Lisboa, Portugal
| | - Paulo Freitas
- Intensive Care Unit, Professor Doutor Fernando Fonseca Hospital, Amadora, Lisboa, Portugal
| | - Frank J Smit
- Department of Paediatrics, Maasstad Hospital, Rotterdam, Zuid-Holland, The Netherlands
| | - Johan van der Lei
- Department of Medical Informatics, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Susanne Greber-Platzer
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Henriëtte A Moll
- Department of General Paediatrics, Erasmus MC Sophia Children Hospital, Rotterdam, Zuid-Holland, The Netherlands
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The Practice of Obtaining a Chest X-Ray in Pediatric Patients Presenting With Their First Episode of Wheezing in the Emergency Department: A Survey of Attending Physicians. Pediatr Emerg Care 2020; 36:16-20. [PMID: 31851079 DOI: 10.1097/pec.0000000000002015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Routine use of chest X-ray (CXR) in pediatric patients presenting with their first episode of wheezing was recommended by many authors. Although recent studies conclude that a CXR is not routinely indicated in these children, there continues to be reports of overuse. OBJECTIVE To examine the attitudes of practicing physicians in ordering CXRs in pediatric patients presenting with their first episode of wheezing to an emergency department (ED) and the factors that influence this practice by surveying ED physicians. METHODS A survey targeting pediatric emergency medicine (PEM) and general emergency medicine attending physicians was distributed electronically to the nearly 3000 members of the PEM Brown listserve and the Pediatric Section of American College of Emergency Physicians listserve. The 14-item survey included closed ended and free text questions to assess the respondent's demographic characteristics, their belief and current practice of obtaining a CXR in pediatric patients presenting with their first episode of wheezing. Data were analyzed using descriptive statistics and χ test. RESULTS Of the 537 attending physicians who participated, their primary residency training was: 42% pediatrics, 54% emergency medicine, and 4% other. Seventy-two percent of participating physicians supervise residents, 54% were board-eligible or -certified in PEM. Thirty percent (95% confidence interval [CI], 26-34) of participants indicated that they would always obtain a CXR in pediatric patients presenting with their first episode of wheezing. Eighty-one percent (95% CI, 75-87) of those who always obtain a CXR believe that it is the standard of care. Of the 376 physicians who do not always obtain a CXR, 18% (95% CI, 15-23) always obtain a CXR under certain age (2 weeks to 12 years, median of 1 year). Physicians who report a primary residency in pediatrics, who supervise residents, who were board-eligible or -certified in PEM, and who were practicing for greater than 5 years were less likely to obtain a CXR (P < 0.001, P < 0.001, P < 0.001, P = 0.001). CONCLUSIONS In our study, a significant number of practicing ED physicians routinely obtain a CXR in children with their first episode of wheezing presenting to the ED. The factors influencing this practice are primary residency training, fellowship training, resident supervision, and years of independent practice. This identifies a target audience that would benefit from education to decrease the overuse of CXRs in children with wheezing.
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14
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Hanna J, Brauer PR, Morse E, Berson E, Mehra S. Epidemiological analysis of croup in the emergency department using two national datasets. Int J Pediatr Otorhinolaryngol 2019; 126:109641. [PMID: 31442871 DOI: 10.1016/j.ijporl.2019.109641] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 07/11/2019] [Accepted: 08/09/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To characterize cases of croup presenting to emergency departments (EDs) nationwide, analyze trends, and determine readmission rates. METHODS Retrospective review of the Nationwide Emergency Department Sample (2007-2014) and the National Hospital Ambulatory Medical Care Survey (2008-2015). RESULTS Both databases provided similar descriptive statistics. Annual mean of 352,388 (weighted) cases in the National Emergency Department Sample (1.35% of ED cases). Average age and male:female ratio 2.50 years and 1.95:1, respectively. Peak incidence was in autumn (October = 13.7%) with troughs in the summer (July = 3.7%). 21.3% received nebulizers, <1% laryngoscopic or airway procedures, 75.1% steroids, and 13.3% antibiotics. Of the patients receiving antibiotics, 16.0% had isolated croup. 3.0% of cases were admitted to the hospital. No trend was identified in the incidence of croup, mean age, or antibiotic and steroid usage. Hospital admission rates decreased (4.0%-2.3%) and nebulizer usage increased (14.6%-27.5%; p < 0.05). 5% of patients represented repeat admissions (were seen within 72 h prior). CONCLUSIONS Croup imposes a significant burden on the ED. Although hospital admissions decreased, annual incidence in the ED remained stable. The majority of cases are in males less than three years old, and 5.0% of patients represented readmissions. Only three-quarters received glucocorticoids despite the proven benefits, including reducing readmission rates. Antibiotic usage was high, with a large number representing potential cases of inappropriate antibiotic use.
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Affiliation(s)
- Jonathan Hanna
- Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, CT, USA
| | - Philip R Brauer
- Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, CT, USA
| | - Elliot Morse
- Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, CT, USA
| | - Elisa Berson
- Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, CT, USA
| | - Saral Mehra
- Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, CT, USA; Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, Yale-New Haven Hospital, Yale Cancer Center, New Haven, CT, USA.
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Rivera-Sepulveda AV, Rebmann T, Gerard J, Charney RL. Physician Compliance With Bronchiolitis Guidelines in Pediatric Emergency Departments. Clin Pediatr (Phila) 2019; 58:1008-1018. [PMID: 31122050 DOI: 10.1177/0009922819850462] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
An online survey was administered through the American Academy of Pediatrics (AAP) Section of Emergency Medicine Survey Listserv in Fall, 2017. Overall compliance was measured as never using chest X-rays, viral testing, bronchodilators, or systemic steroids. Practice compliance was measured as never using those modalities in a clinical vignette. Chi-square tests assessed differences in compliance between modalities. t tests assessed differences on agreement with each AAP statement. Multivariate logistic regression determined factors associated with overall compliance. Response rate was 47%. A third (35%) agreed with all 7 AAP statements. There was less compliance with ordering a bronchodilator compared with chest X-ray, viral testing, or systemic steroid. There was no association between compliance and either knowledge or agreement with the guideline. Physicians with institutional bronchiolitis guidelines were more likely to be practice compliant. Few physicians were compliant with the AAP bronchiolitis guideline, with bronchodilator misuse being most pronounced. Institutional bronchiolitis guidelines were associated with physician compliance.
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Affiliation(s)
| | - Terri Rebmann
- 2 Saint Louis University Institute of Biosecurity, Saint Louis, MO, USA
| | - James Gerard
- 1 Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Rachel L Charney
- 1 Saint Louis University School of Medicine, Saint Louis, MO, USA
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16
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Kocher KE, Arora R, Bassin BS, Benjamin LS, Bolton M, Dennis BJ, Ham JJ, Krupp SS, Levasseur KA, Macy ML, O'Neil BJ, Pribble JM, Sherwin RL, Sroufe NS, Uren BJ, Nypaver MM. Baseline Performance of Real-World Clinical Practice Within a Statewide Emergency Medicine Quality Network: The Michigan Emergency Department Improvement Collaborative (MEDIC). Ann Emerg Med 2019; 75:192-205. [PMID: 31256906 DOI: 10.1016/j.annemergmed.2019.04.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 03/11/2019] [Accepted: 04/25/2019] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE Large-scale quality and performance measurement across unaffiliated hospitals is an important strategy to drive practice change. The Michigan Emergency Department Improvement Collaborative (MEDIC), established in 2015, has baseline performance data to identify practice variation across 15 diverse emergency departments (EDs) on key emergency care quality indicators. METHODS MEDIC is a unique physician-led partnership supported by a major third-party payer. Member sites contribute electronic health record data and trained abstractors add supplementary data for eligible cases. Quality measures include computed tomography (CT) appropriateness for minor head injury, using the Canadian CT Head Rule for adults and Pediatric Emergency Care Applied Network rules for children; chest radiograph use for children with asthma, bronchiolitis, and croup; and diagnostic yield of CTs for suspected pulmonary embolism. Baseline performance was established with statistical process control charts. RESULTS From June 1, 2016, to October 31, 2017, the MEDIC registry contained 1,124,227 ED visits, 23.2% for children (<18 years). Overall baseline performance included the following: 40.9% of adult patients with minor head injury (N=11,857) had appropriate CTs (site range 24.3% to 58.6%), 10.3% of pediatric minor head injury cases (N=11,183) exhibited CT overuse (range 5.8% to 16.8%), 38.1% of pediatric patients with a respiratory condition (N=18,190) received a chest radiograph (range 9.0% to 62.1%), and 8.7% of pulmonary embolism CT results (N=16,205) were positive (range 7.5% to 14.3%). CONCLUSION Performance varied greatly, with demonstrated opportunity for improvement. MEDIC provides a robust platform for emergency physician engagement across ED practice settings to improve care and is a model for other states.
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Affiliation(s)
- Keith E Kocher
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI.
| | - Rajan Arora
- Department of Emergency Medicine and Pediatrics, Wayne State University, Detroit, MI; Children's Hospital of Michigan, Detroit, MI
| | - Benjamin S Bassin
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | | | - Michaelina Bolton
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI; Hurley Medical Center, Flint, MI
| | - Blaine J Dennis
- Beaumont Health System, Royal Oak, MI; Oakland University William Beaumont School of Medicine, Rochester, MI; Beaumont Hospital, Royal Oak and Troy, MI
| | - Jason J Ham
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI; Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Seth S Krupp
- Department of Emergency Medicine, Wayne State University, Detroit, MI; Henry Ford Health System, Detroit, MI
| | - Kelly A Levasseur
- Oakland University William Beaumont School of Medicine, Rochester, MI; Beaumont Health System, Royal Oak, MI; Beaumont Hospital, Royal Oak and Troy, MI; Beaumont Children's Hospital, Royal Oak, MI
| | - Michelle L Macy
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI; Child Health Evaluation and Research (CHEAR) Center, University of Michigan Medical School, Ann Arbor, MI; Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Brian J O'Neil
- Department of Emergency Medicine, Wayne State University, Detroit, MI
| | - James M Pribble
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Robert L Sherwin
- Department of Emergency Medicine, Wayne State University, Detroit, MI
| | - Nicole S Sroufe
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI; Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | - Bradley J Uren
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Michele M Nypaver
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI; Department of Pediatrics, University of Michigan, Ann Arbor, MI
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Gong C, Byczkowski T, McAneney C, Goyal MK, Florin TA. Emergency Department Management of Bronchiolitis in the United States. Pediatr Emerg Care 2019; 35:323-329. [PMID: 28441240 PMCID: PMC5654708 DOI: 10.1097/pec.0000000000001145] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to examine differences between general and pediatric emergency departments (PEDs) in adherence to the American Academy of Pediatrics bronchiolitis management guidelines. METHODS We conducted a nationally representative study of ED visits by infants younger than 24 months with bronchiolitis from 2002 to 2011 using the National Hospital Ambulatory Medical Care Survey. Diagnostic testing (complete blood counts, radiographs) and medication use (albuterol, corticosteroids, antibiotics and intravenous fluids) in general emergency departments (GEDs) were compared with those in PEDs before and after 2006 American Academy of Pediatrics guideline publication. Weighted percentages were compared, and logistic regression evaluated the association between ED type and resource use. RESULTS Of more than 2.5 million ED visits for bronchiolitis from 2002 to 2011, 77.3% occurred in GEDs. General emergency departments were more likely to use radiography (62.7% vs 42.1%; adjusted odds ratio [aOR], 2.4; 95% confidence interval [CI], 1.4-4.1), antibiotics (41.3% vs 18.8%; aOR, 2.8; 95% CI, 1.5-5.2), and corticosteroids (24.3% vs 12.5%; aOR, 2.1; 95% CI, 1.0-4.5) compared with PEDs. Compared with preguideline, after guideline publication PEDs had a greater decrease in radiography use (-19.7%; 95% CI, -39.3% to -0.03%) compared with GEDs (-12.2%; 95% CI, -22.3% to -2.1%), and PEDs showed a significant decline in corticosteroid use (-12.4%; 95% CI, -22.1% to -2.8%), whereas GEDs showed no significant decline (-4.6%; 95% CI, -13.5% to 4.3%). CONCLUSIONS The majority of ED visits for bronchiolitis in the United States occurred in GEDs, yet GEDs had increased use of radiography, corticosteroids, and antibiotics and did not show substantial declines with national guideline publication. Given that national guidelines discourage the use of such tests and treatments in the management of bronchiolitis, efforts are required to decrease ED use of these resources in infants with bronchiolitis, particularly in GEDs.
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Affiliation(s)
- Constance Gong
- Division of Emergency Medicine, Emory University School of Medicine and Children's Healthcare of Atlanta
| | - Terri Byczkowski
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Constance McAneney
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Monika K. Goyal
- Division of Emergency Medicine, Children's National Health System, The George Washington University
| | - Todd A. Florin
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
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18
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Zook HG, Payne NR, Puumala SE, Burgess K, Kharbanda AB. Racial/Ethnic Variation in Emergency Department Care for Children With Asthma. Pediatr Emerg Care 2019; 35:209-215. [PMID: 28926508 PMCID: PMC5857394 DOI: 10.1097/pec.0000000000001282] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To assess the variation between racial/ethnic groups in emergency department (ED) treatment of asthma for pediatric patients. METHODS This study was a cross-sectional analysis of pediatric (2-18 years) asthma visits among 6 EDs in the Upper Midwest between June 2011 and May 2012. We used mixed-effects logistic regression to assess the odds of receiving steroids, radiology tests, and returning to the ED within 30 days. We conducted a subanalysis of asthma visits where patients received at least 1 albuterol treatment in the ED. RESULTS The sample included 2909 asthma visits by 1755 patients who were discharged home from the ED. After adjusting for demographics, insurance type, and triage score, African American (adjusted odds ratio [aOR], 1.78; 95% confidence interval [CI], 1.40-2.26) and Hispanic (aOR, 1.64; 95% CI, 1.22-2.22) patients had higher odds of receiving steroids compared with whites. African Americans (aOR, 0.58; 95% CI, 0.46-0.74) also had lower odds of radiological testing compared with whites. Asians had the lowest odds of 30-day ED revisits (aOR, 0.26; 95% CI, 0.08-0.84), with no other significant differences detected between racial/ethnic groups. Subgroup analyses of asthma patients who received albuterol revealed similar results, with American Indians showing lower odds of radiological testing as well (aOR, 0.47; 95% CI, 0.22-1.01). CONCLUSIONS In this study, children from racial/ethnic minority groups had higher odds of steroid administration and lower odds of radiological testing compared with white children. The underlying reasons for these differences are likely multifactorial, including varying levels of disease severity, health literacy, and access to care.
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Affiliation(s)
- Heather G. Zook
- Department of Research and Sponsored Programs, Children’s Hospitals and Clinics of Minnesota, 2525 Chicago Avenue South, Minneapolis, MN 55404
- Department of Evaluation, Professional Data Analysts, Inc., 219 Main Street SE, Suite 302, Minneapolis, MN 55414
| | - Nathaniel R. Payne
- Department of Research and Sponsored Programs, Children’s Hospitals and Clinics of Minnesota, 2525 Chicago Avenue South, Minneapolis, MN 55404
- Department of Quality and Safety, Children’s Hospitals and Clinics of Minnesota, 2525 Chicago Avenue South, Minneapolis, MN 55404
| | - Susan E. Puumala
- Center for Health Outcomes and Prevention Research, Sanford Research, 2301 E 60th Street North, Sioux Falls, SD 57104
- Department of Pediatrics, Sanford School of Medicine at the University of South Dakota, 1400 W 22nd Street, Sioux Falls, SD 57105
| | - Katherine Burgess
- Center for Health Outcomes and Prevention Research, Sanford Research, 2301 E 60th Street North, Sioux Falls, SD 57104
- Department of Epidemiology, Colorado School of Public Health at the University of Colorado at Denver, 13001 East 17 Place, Aurora, CO 80045
| | - Anupam B. Kharbanda
- Department of Emergency Medicine, Children’s Hospitals and Clinics of Minnesota, 2525 Chicago Avenue South, Minneapolis, MN 55404
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Poole NM, Shapiro DJ, Fleming-Dutra KE, Hicks LA, Hersh AL, Kronman MP. Antibiotic Prescribing for Children in United States Emergency Departments: 2009-2014. Pediatrics 2019; 143:peds.2018-1056. [PMID: 30622156 PMCID: PMC6581044 DOI: 10.1542/peds.2018-1056] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/23/2018] [Indexed: 01/21/2023] Open
Abstract
UNLABELLED : media-1vid110.1542/5972296744001PEDS-VA_2018-1056Video Abstract OBJECTIVES: To characterize and compare ambulatory antibiotic prescribing for children in US pediatric and nonpediatric emergency departments (EDs). METHODS A cross-sectional retrospective study of patients aged 0 to 17 years discharged from EDs in the United States was conducted by using the 2009-2014 National Hospital Ambulatory Medical Care Survey ED data. We estimated the proportion of ED visits resulting in antibiotic prescriptions, stratified by antibiotic spectrum, class, diagnosis, and ED type ("pediatric" defined as >75% of visits by patients aged 0-17 years, versus "nonpediatric"). Multivariable logistic regression was used to determine factors independently associated with first-line, guideline-concordant prescribing for acute otitis media, pharyngitis, and sinusitis. RESULTS In 2009-2014, of the 29 million mean annual ED visits by children, 14% (95% confidence interval [CI]: 10%-20%) occurred at pediatric EDs. Antibiotics overall were prescribed more frequently in nonpediatric than pediatric ED visits (24% vs 20%, P < .01). Antibiotic prescribing frequencies were stable over time. Of all antibiotics prescribed, 44% (95% CI: 42%-45%) were broad spectrum, and 32% (95% CI: 30%-34%, 2.1 million per year) were generally not indicated. Compared with pediatric EDs, nonpediatric EDs had a higher frequency of prescribing macrolides (18% vs 8%, P < .0001) and a lower frequency of first-line, guideline-concordant prescribing for the respiratory conditions studied (77% vs 87%, P < .001). CONCLUSIONS Children are prescribed almost 7 million antibiotic prescriptions in EDs annually, primarily in nonpediatric EDs. Pediatric antibiotic stewardship efforts should expand to nonpediatric EDs nationwide, particularly regarding avoidance of antibiotic prescribing for conditions for which antibiotics are not indicated, reducing macrolide prescriptions, and increasing first-line, guideline-concordant prescribing.
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Affiliation(s)
- Nicole M. Poole
- Pediatric Infectious Diseases, University of Washington,
Seattle, WA
| | | | | | - Lauri A. Hicks
- Division of Healthcare Quality Promotion, Centers for
Disease Control and Prevention, Atlanta, GA
| | - Adam L. Hersh
- Pediatric Infectious Diseases, University of Utah, Salt
Lake City, UT
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20
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Barata I, Auerbach M, Badaki‐Makun O, Benjamin L, Joseph MM, Lee MO, Mears K, Petrack E, Wallin D, Ishimine P, Denninghoff KR. A Research Agenda to Advance Pediatric Emergency Care Through Enhanced Collaboration Across Emergency Departments. Acad Emerg Med 2018; 25:1415-1426. [PMID: 30353946 DOI: 10.1111/acem.13642] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 10/06/2018] [Accepted: 10/10/2018] [Indexed: 11/26/2022]
Abstract
In 2018, the Society for Academic Emergency Medicine and the journal Academic Emergency Medicine (AEM) convened a consensus conference entitled, "Academic Emergency Medicine Consensus Conference: Aligning the Pediatric Emergency Medicine Research Agenda to Reduce Health Outcome Gaps." This article is the product of the breakout session, "Emergency Department Collaboration-Pediatric Emergency Medicine in Non-Children's Hospital"). This subcommittee consisting of emergency medicine, pediatric emergency medicine, and quality improvement (QI) experts, as well as a patient advocate, identified main outcome gaps in the care of children in the emergency departments (EDs) in the following areas: variations in pediatric care and outcomes, pediatric readiness, and gaps in knowledge translation. The goal for this session was to create a research agenda that facilitates collaboration and partnering of diverse stakeholders to develop a system of care across all ED settings with the aim of improving quality and increasing safe medical care for children. The following recommended research strategies emerged: explore the use of technology as well as collaborative networks for education, research, and advocacy to develop and implement patient care guidelines, pediatric knowledge generation and dissemination, and pediatric QI and prepare all EDs to care for the acutely ill and injured pediatric patients. In conclusion, collaboration between general EDs and academic pediatric centers on research, dissemination, and implementation of evidence into clinical practice is a solution to improving the quality of pediatric care across the continuum.
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Affiliation(s)
- Isabel Barata
- Department of Pediatrics and Emergency Medicine Northwell Health System Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Manhasset NY
| | - Marc Auerbach
- Pediatrics and Emergency Medicine Yale University School of Medicine New Haven CT
| | | | - Lee Benjamin
- Pediatric Emergency Center Saint Joseph Mercy Health System Department of Emergency Medicine University of Michigan Ann Arbor MI
| | - Madeline M. Joseph
- Department of Emergency Medicine University of Florida College of Medicine–Jacksonville Jacksonville FL
| | - Moon O. Lee
- Department of Emergency Medicine Stanford University School of Medicine Stanford CA
| | | | | | - Dina Wallin
- Division of Pediatric Emergency Medicine Department of Emergency Medicine University of California at San Francisco San Francisco CA
| | | | - Kurt R. Denninghoff
- Department of Emergency Medicine University of Arizona College of Medicine Tucson AZ
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21
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Michelson KA, Lyons TW, Hudgins JD, Levy JA, Monuteaux MC, Finkelstein JA, Bachur RG. Use of a National Database to Assess Pediatric Emergency Care Across United States Emergency Departments. Acad Emerg Med 2018; 25:1355-1364. [PMID: 29858524 DOI: 10.1111/acem.13489] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 05/23/2018] [Accepted: 05/31/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Differences in emergency care for children exist between general and pediatric emergency departments (EDs). Some pediatric quality measures are available but are not routinely employed nationwide. We sought to create a short list of applied measures that would provide a starting point for EDs to measure pediatric emergency care quality and to compare care between general and pediatric EDs for these measures. METHODS Previously reported lists comprising 465 pediatric emergency care quality measures were reconciled. Preset criteria were used to create a diverse list of quality measures measurable using a national database. We used the National Hospital Ambulatory Medical Care Survey from 2010 to 2015 to measure performance. Measures were excluded for total observation counts under a prespecified power threshold, being unmeasurable in the data set, or for missing clear definitions. Using survey-weighted statistics, we reported summary performance (mean, proportion, or count) with 95% confidence intervals for each analyzed quality measure and compared general and pediatric ED performance. RESULTS Among 465 quality measures, 28 (6%) were included in the analysis, including seven condition-specific measures and 21 general measures. We analyzed a sample of 36,430 visits corresponding to 179.0 million survey-weighted ED visits, of which 150.8 million (84.3%) were in general EDs. Performance was better in pediatric EDs for three of seven condition-specific measures, including antibiotics for viral infections (-6.2%), chest X-rays for asthma (-18.7%), and topical anesthesia for wound closures (+25.7%). Performance was similar for four of seven condition-specific measures: computed tomography for head trauma, steroids for asthma, steroids for croup, and oral rehydration for dehydration. Compared with pediatric EDs, general EDs discharged and transferred higher proportions of children, had shorter lengths of stay, and sent patients home with fewer prescriptions. General EDs obtained fewer pain scores for injured children. Pediatric EDs had a lower proportion of pediatric visits in which patients left against medical advice. General and pediatric EDs had similar rates of mortality, left without being seen, incomplete vital signs, labs in nonacute patients, and similar numbers of medications given per patient. CONCLUSIONS Using a national sample of ED visits, we demonstrated the feasibility of using nationally representative data to assess quality measures for children cared for in the ED. Differences between pediatric and general ED care identify targets for quality improvement.
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Affiliation(s)
| | - Todd W. Lyons
- Division of Emergency Medicine Boston Children's Hospital Boston MA
| | - Joel D. Hudgins
- Division of Emergency Medicine Boston Children's Hospital Boston MA
| | - Jason A. Levy
- Division of Emergency Medicine Boston Children's Hospital Boston MA
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Abstract
OBJECTIVES The aim of this study was to describe the resource utilization for children with common pediatric conditions treated in academic and nonacademic emergency departments (EDs). METHODS We performed a retrospective, cross-sectional descriptive study using the National Hospital Ambulatory Medical Care Survey Data from 1995 to 2010 including children less than 18 years old with a diagnosis of asthma, bronchiolitis, croup, gastroenteritis, fever, febrile seizure, or afebrile seizure. Academic EDs (A-ED) were those with greater than 25% of patients seen by a trainee. For each condition, we reported the proportion of testing, medications, and disposition between A-ED and nonacademic EDs (NA-ED). RESULTS From 1995 to 2010, approximately 450,000,000 estimated pediatric visits are represented by the survey based on 122,811 actual visits. For most common conditions, testing and disposition were comparable; however, some variation was noted. Among patients with bronchiolitis, a higher proportion of patients was admitted and had radiographs in NA-EDs (18% vs 10% and 56% vs 45%, respectively). For children with croup, radiographs were performed more often at NA-EDs (27% vs 6%). Among those with febrile seizures, more lumbar punctures were performed in NA-EDs (14% vs 0%). In children with afebrile seizures, more head computed tomography scans were obtained at NA-EDs (34% vs 21%). CONCLUSION Among pediatric patients with croup, bronchiolitis, and febrile and afebrile seizure, higher resource utilization and admissions were observed in NA-EDs. These preliminary findings from a national survey require a more detailed investigation into the variation in care between A-ED and NA-ED settings.
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23
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Simmonds JC, Tuomi A, Groblewski JC. High rates of subglottic stenosis seen in African-American children admitted with severe croup to hospitals in the United States between 2003 and 2013. Respir Med 2018; 143:56-60. [DOI: 10.1016/j.rmed.2018.08.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/27/2018] [Accepted: 08/28/2018] [Indexed: 12/14/2022]
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25
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Abstract
Advances in medical imaging are invaluable in the care of pediatric patients in the emergent setting. The diagnostic accuracy offered by studies using ionizing radiation, such as plain radiography, computed tomography, and fluoroscopy, are not without inherent risks. This article reviews the evidence supporting the risk of ionizing radiation from medical imaging as well as discusses clinical scenarios in which clinicians play an important role in supporting the judicious use of imaging studies.
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Affiliation(s)
- Amy L Puchalski
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Carolinas Medical Center, Levine Children's Hospital, 1000 Blythe Boulevard, Charlotte, NC 28203, USA.
| | - Christyn Magill
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Carolinas Medical Center, Levine Children's Hospital, 1000 Blythe Boulevard, Charlotte, NC 28203, USA
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26
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Walls TA. Pediatric Asthma in the Community Emergency Department: Room for Improvement and Aligned Incentives. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2018. [DOI: 10.1016/j.cpem.2018.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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27
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Mussman GM, Lossius M, Wasif F, Bennett J, Shadman KA, Walley SC, Destino L, Nichols E, Ralston SL. Multisite Emergency Department Inpatient Collaborative to Reduce Unnecessary Bronchiolitis Care. Pediatrics 2018; 141:peds.2017-0830. [PMID: 29321255 DOI: 10.1542/peds.2017-0830] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/13/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES There is high variation in the care of acute viral bronchiolitis. We sought to promote collaboration between emergency department (ED) and inpatient (IP) units with the goal of reducing unnecessary testing and treatment. METHODS Multisite collaborative with improvement teams co-led by ED and IP physicians and a 1-year period of active participation. The intervention consisted of a multicomponent change package, regular webinars, and optional coaching. Data were collected by chart review for December 2014 through March 2015 (baseline) and December 2015 to March 2016 (improvement period). Patients <24 months of age with a primary diagnosis of bronchiolitis and without ICU admission, prematurity, or chronic lung or heart disease were eligible for inclusion. Control charts were used to detect improvement. Achievable benchmarks of care were calculated for each measure. RESULTS Thirty-five hospitals with 5078 ED patients and 4389 IPs participated. Use of bronchodilators demonstrated special cause for the ED (mean centerline shift: 37.1%-24.5%, benchmark 5.8%) and IP (28.4%-17.7%, benchmark 9.1%). Project mean ED viral testing decreased from 42.6% to 25.4% after revealing special cause with a 3.9% benchmark, whereas chest radiography (30.9%), antibiotic use (6.2%), and steroid use (7.6%) in the ED units did not change. IP steroid use decreased from 7.2% to 4.0% after special cause with 0.0% as the benchmark. Within-site ED and IP performance was modestly correlated. CONCLUSIONS Collaboration between ED and IP units was associated with a decreased use of unnecessary tests and therapies in bronchiolitis; top performers used few unnecessary tests or treatments.
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Affiliation(s)
- Grant M Mussman
- Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio;
| | - Michele Lossius
- Shands Children's Hospital, University of Florida Health, Gainesville, Florida
| | - Faiza Wasif
- American Academy of Pediatrics, Elk Grove Village, Illinois
| | - Jeffrey Bennett
- Department of General Pediatrics, University of Tennessee College of Medicine-Chattanooga, Chattanooga, Tennessee
| | - Kristin A Shadman
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Susan C Walley
- Children's of Alabama and Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lauren Destino
- Lucile Packard Children's Hospital School of Medicine and Department of Pediatrics, Stanford University, Stanford, California
| | - Elizabeth Nichols
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire; and
| | - Shawn L Ralston
- Children's Hospital at Dartmouth-Hitchcock, Lebanon, New Hampshire
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28
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Markham JL, Hall M, Bettenhausen JL, Myers AL, Puls HT, McCulloh RJ. Variation in Care and Clinical Outcomes in Children Hospitalized With Orbital Cellulitis. Hosp Pediatr 2017; 8:28-35. [PMID: 29208694 DOI: 10.1542/hpeds.2017-0040] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To describe variation in the care of children hospitalized with orbital cellulitis and to determine associations with length of stay (LOS), emergency department (ED) revisits, and hospital readmissions. METHODS By using the Pediatric Health Information System, we performed a multicenter, retrospective study of children aged 2 months to 18 years with a primary International Classification of Diseases, Ninth Revision, Clinical Modification discharge diagnosis code for orbital cellulitis from 2007 to 2014. We assessed hospital-level variation in the use of diagnostic tests, corticosteroids, and antibiotics individually and in aggregate for association with outcomes (LOS, ED revisits, readmissions) after risk-adjusting for important clinical and demographic factors. RESULTS A total of 1828 children met inclusion criteria. Complete blood cell counts (median [interquartile range]: 81.8% [66.7-89.6]), C-reactive protein levels (57.1% [22.2-84.0]), blood cultures (57.9% [48.9-63.6]), and computed tomography imaging (74.7% [66.7-81.0]) were the most frequently performed diagnostic tests, with significant variation observed across hospitals (all P < .001). Corticosteroids were used in 29.2% of children (interquartile range: 18.4-37.5). There was significant variation in antibiotic exposure across hospitals (P < .001). Increased total diagnostic test usage was associated with increased LOS (P = .044), but not with 30-day ED revisits (P = .176) or readmissions (P = .403). CONCLUSIONS Children hospitalized with orbital cellulitis experience wide variation in clinical management. Increased hospital-level usage is associated with increased LOS. Our findings highlight a critical need to identify treatment strategies that optimize resource use and outcomes for children hospitalized with orbital cellulitis.
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Affiliation(s)
| | - Matthew Hall
- Divisions of Pediatric Hospital Medicine and.,Children's Hospital Association, Lenexa, Kansas
| | | | - Angela L Myers
- Divisions of Pediatric Hospital Medicine and.,Infectious Diseases, Children's Mercy Kansas City, Kansas City, Missouri; and
| | | | - Russell J McCulloh
- Divisions of Pediatric Hospital Medicine and.,Infectious Diseases, Children's Mercy Kansas City, Kansas City, Missouri; and
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29
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Rees CA, Pryor S, Choi B, Senthil MV, Tsarouhas N, Myers SR, Monuteaux MC, Bachur RG, Li J. The influence of insurance type on interfacility pediatric emergency department transfers. Am J Emerg Med 2017; 35:1907-1909. [DOI: 10.1016/j.ajem.2017.07.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 07/14/2017] [Accepted: 07/14/2017] [Indexed: 10/19/2022] Open
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30
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Yun BJ, Chou SC, Nagurney JM, White BA, Wittmann CW, Raja AS. ED utilization of medical clearance testing for psychiatric admission: National Hospital Ambulatory Medical Care Survey analysis. Am J Emerg Med 2017; 36:745-748. [PMID: 28988848 DOI: 10.1016/j.ajem.2017.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 10/03/2017] [Accepted: 10/03/2017] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Routine medical clearance testing of emergency department (ED) patients with acute psychiatric illnesses in the absence of a medical indication has minimal proven utility. Little is known about the variations in clinical practice of ordering medical clearance tests. METHODS This study was an analysis of data from the annual United States National Hospital Ambulatory Medical Care Survey from 2010 to 2014. The study population was defined as ED visits by patients ≥18years old admitted to a psychiatric facility. We sought to determine the percentage of these ED visits in which at least one medical clearance test was ordered. Using a multivariate logistic regression model, we also evaluated whether patient visit factors or regional variation was associated with use of medical clearance tests. RESULT A medical clearance test was ordered in 80.4% of ED visits ending with a psychiatric admission. Multivariate logistic regression demonstrated a statistically significant increased odds ratio (OR) of medical clearance testing based on age (OR 1.02, 95%CI 1.01, 1.03), among visits involving an injury or poisoning (OR 2.38, 95%CI 1.54, 3.68), and in the Midwest region as compared to the Northeast region (OR 2.2, 95% confidence interval [CI] 1.09, 4.46), after adjusting for other predictors. DISCUSSION Our study demonstrated that, on a national level, 4 out of 5 ED visits resulting in a psychiatric facility admission had a medical clearance test ordered. Future research is needed to investigate the reasons underlying the discrepancies in ordering patterns across the U.S., including the effect of local psychiatric admission policies.
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Affiliation(s)
- Brian J Yun
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA; Center for Research in Emergency Department Operations (CREDO), Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Shih-Chuan Chou
- Harvard Medical School, Boston, MA, USA; Division of Health Policy Research and Translation, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Justine M Nagurney
- Harvard Medical School, Boston, MA, USA; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Institute for Aging Research, Hebrew Senior Life, Boston, MA, USA
| | - Benjamin A White
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA; Center for Research in Emergency Department Operations (CREDO), Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Curtis W Wittmann
- Harvard Medical School, Boston, MA, USA; Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Ali S Raja
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA; Center for Research in Emergency Department Operations (CREDO), Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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31
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Rivera-Sepulveda A, Garcia-Rivera EJ. Epidemiology of bronchiolitis: a description of emergency department visits and hospitalizations in Puerto Rico, 2010-2014. Trop Med Health 2017; 45:24. [PMID: 29021713 PMCID: PMC5623968 DOI: 10.1186/s41182-017-0064-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 08/11/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Little is known about the epidemiology of bronchiolitis as a clinical diagnosis and its impact on emergency department visits and hospitalizations in tropical and semitropical regions. We described the epidemiology of bronchiolitis emergency visits and hospitalizations, its temporal trend and geographic distribution in Puerto Rico between 2010 and 2014. METHODS We performed a retrospective descriptive analysis of a representative sample of privately insured children with bronchiolitis from January 2010 to December 2014. Data was provided by the largest private health insurer in Puerto Rico and identified children < 24 months of age with bronchiolitis by International Classification of Diseases, Ninth Revision code 466, 466.11, and 466.19. Chi-square and one-way ANOVA compared sex, age, diagnosis, and severity across the years. Joinpoint Poisson regression analysis evaluated the temporal trend distribution of bronchiolitis hospitalizations per calendar year. A P value less than 0.05 was statistically significant. RESULTS During the study period, the annual proportion of emergency department visits and hospitalizations due to bronchiolitis increased from 3 to 5%, and 26 to 38%, respectively. The annual incidence rate of hospitalizations was 3.2 per 1000 privately insured children < 24 months. Non-RSV bronchiolitis was the most frequent diagnosis (51%). Hospitalizations occurred year-round, but increased significantly from August through December. Most children hospitalized resided in the metropolitan San Juan (35%) and surrounding urban areas. Total hospital charges decreased from $3.78 to $3.74 million, with an average cost per hospitalization of $4320.12 (11.3% increase; P = 0.0015). CONCLUSIONS This is the first study that evaluates the epidemiological characteristics of bronchiolitis in a primarily Hispanic population, living in a tropical country, and using data from a privately insured population. We found a small but significant increase in proportion of emergency visits and hospitalizations. Temporal trend shows year-round hospitalizations with an earlier seasonal peak and longer duration, consistent with Puerto Rico's seasonal rainfall throughout the study period. Further studies are needed to elucidate whether this epidemiologic pattern can also be seen in publicly insured children and whether Hispanic ethnicity is a risk factor for increased hospitalizations or is related to health disparities in the US healthcare system.
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Affiliation(s)
- Andrea Rivera-Sepulveda
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Saint Louis University School of Medicine, 1402 S. Grand Boulevard – Glennon Hall, Room 2717, 63104 Saint Louis, MO USA
- School of Health Professions, University of Puerto Rico Medical Sciences Campus, and School of Medicine, San Juan, Puerto Rico
| | - Enid J. Garcia-Rivera
- School of Health Professions, University of Puerto Rico Medical Sciences Campus, and School of Medicine, San Juan, Puerto Rico
- Endowed Health Services, University of Puerto Rico School of Medicine, Medical Sciences Campus, San Juan, Puerto Rico
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Huang IA, Jaing TH, Wu CT, Chang CJ, Hsia SH, Huang N. A tale of two systems: practice patterns of a single group of emergency medical physicians in Taiwan and China. BMC Health Serv Res 2017; 17:642. [PMID: 28893261 PMCID: PMC5594439 DOI: 10.1186/s12913-017-2606-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 09/07/2017] [Indexed: 12/02/2022] Open
Abstract
Background The quality of pediatric emergency care has been a major concern in health care. Following a series of health system reforms in China, it is important to do this assessment of pediatric emergency care, and to explore potential influences of health care system. This study aimed to compare practice differences in treating children with respiratory illnesses in two emergency department (ED) settings within different health care systems: China and Taiwan. Methods A pooled cross-sectional hospital-based study was conducted in two tertiary teaching hospitals in Xiamen, China and Keelung, Taiwan belong to the same hospital chain group. A team of 21 pediatricians rotated between the EDs of the two hospitals from 2009 to 2012. There were 109,705 ED encounters treated by the same team of pediatricians and 6596 visits were analyzed for common respiratory illnesses. Twelve quality measures in process and outcomes of asthma, bronchiolitis and croup were reported. Descriptive statistics and multiple logistic regression models were applied to assess. In order to demonstrate the robustness of our findings, we analyzed the data using an alternative modeling technique, multilevel modeling. Results After adjustment, children with asthma presented to the ED in China had a significantly 76% lower likelihood to be prescribed a chest radiograph, and a 98% lower likelihood to be prescribed steroids and discharged home than those in Taiwan. Also, children with asthma presented to the ED in China had significantly 7.76 times higher risk to incur 24-72 h return visits. Furthermore, children with bronchiolitis in China (Odds ratio (OR): 0.21; 95% Confidence interval (CI): 0.17-0.28) were significantly less likely to be prescribed chest radiograph, but were significantly more likely to be prescribed antibiotics (OR: 2.19; 95% CI: 1.46-3.28). Conclusions This study illustrated that although high quality care depends on better assessment of physician performance, the delivery of pediatric emergency care differed significantly between these two healthcare systems after holding the care providers the same and adjusting for important patient characteristics. The findings suggest that the features of the health care system may play a significant role.
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Affiliation(s)
- I-Anne Huang
- Department of Pediatrics, Chang Gung Memorial Hospital, No. 222, Maijin Rd., Keelung, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, No.259, Wenhua 1st Rd., Guishan Dist, Taoyuan City, 333, Taiwan.,Institute of Public Health, National Yang Ming University, No.155, Sec. 2, Linong St., Beitou Dist, Taipei City, 112, Taiwan.,Department of Pediatrics, Chang Gung Memorial Hospital, No.123, Xiafei Rd., Haicang Dist, Xiamen City, China
| | - Tang-Her Jaing
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, No.259, Wenhua 1st Rd., Guishan Dist, Taoyuan City, 333, Taiwan.,Department of Pediatrics, Chang Gung Children's Hospital, 5. Fu-hsing St., Guishan Dist, Taoyuan City, 333, Taiwan
| | - Chang-Teng Wu
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, No.259, Wenhua 1st Rd., Guishan Dist, Taoyuan City, 333, Taiwan.,Department of Pediatrics, Chang Gung Children's Hospital, 5. Fu-hsing St., Guishan Dist, Taoyuan City, 333, Taiwan
| | - Chee-Jen Chang
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, No.259, Wenhua 1st Rd., Guishan Dist, Taoyuan City, 333, Taiwan.,Resources Center for Clinical Research, Chang Gung Memorial Hospital, 5. Fu-hsing St., Guishan Dist, Taoyuan City, 333, Taiwan
| | - Shan-Hsuan Hsia
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, No.259, Wenhua 1st Rd., Guishan Dist, Taoyuan City, 333, Taiwan.,Department of Pediatrics, Chang Gung Children's Hospital, 5. Fu-hsing St., Guishan Dist, Taoyuan City, 333, Taiwan
| | - Nicole Huang
- Institute of Hospital and Healthcare Administration, National Yang Ming University, Room 101, Medical Building ll, No.155, Sec. 2, Linong St., Beitou Dist, Taipei City, 112, Taiwan.
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Kornblith AE, Fahimi J, Kanzaria HK, Wang RC. Predictors for under-prescribing antibiotics in children with respiratory infections requiring antibiotics. Am J Emerg Med 2017; 36:218-225. [PMID: 28774769 DOI: 10.1016/j.ajem.2017.07.081] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 07/25/2017] [Accepted: 07/26/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND/OBJECTIVE Previous studies showed variability in the use of diagnostic and therapeutic resources for children with febrile acute respiratory tract infections (ARTI), including antibiotics. Unnecessary antibiotic use has important public and individual health outcomes, but missed antibiotic prescribing also has important consequences. We sought to determine factors associated with antibiotic prescribing in pediatric ARTI, specifically those with pneumonia. METHODS We assessed national trends in the evaluation and treatment of ARTI for pediatric emergency department (ED) patients by analyzing the National Hospital Ambulatory Medical Care Survey from 2002 to 2013. We identified ED patients aged ≤18 with a reason for visit of ARTI, and created 4 diagnostic categories: pneumonia, ARTI where antibiotics are typically indicated, ARTI where antibiotics are typically not indicated, and "other" diagnoses. Our primary outcome was factors associated with the administration or prescription of antibiotics. A multivariate logistic regression model was fit to identify risk factors for underuse of antibiotics when they were indicated. RESULTS We analyzed 6461 visits, of which 10.2% of the population had a final diagnosis of pneumonia and 86% received antibiotics. 41.5% of patients were diagnosed with an ARTI requiring antibiotics, of which 53.8% received antibiotics. 26.6% were diagnosed with ARTI not requiring antibiotics, of which 36.0% received antibiotics. Black race was a predictor for the underuse of antibiotics in ARTIs that require antibiotics (OR: 0.72; 95% CI: 0.58-0.90). CONCLUSIONS For pediatric patients presenting to the ED with pneumonia and ARTI requiring antibiotics, we found that black race was an independent predictor of antibiotic underuse.
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Affiliation(s)
- Aaron E Kornblith
- Department of Emergency Medicine & Pediatrics, University of California, San Francisco, 550 16th Street, San Francisco, CA 94143, United States; Department of Emergency Medicine, University of California, San Francisco, 1001 Potrero Ave, San Francisco, CA 94110, United States.
| | - Jahan Fahimi
- Department of Emergency Medicine, University of California, San Francisco, 1001 Potrero Ave, San Francisco, CA 94110, United States
| | - Hemal K Kanzaria
- Department of Emergency Medicine, University of California, San Francisco, 1001 Potrero Ave, San Francisco, CA 94110, United States
| | - Ralph C Wang
- Department of Emergency Medicine, University of California, San Francisco, 1001 Potrero Ave, San Francisco, CA 94110, United States
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Abstract
OBJECTIVES Recent research has shown significant variation in rates of computed tomography (CT) use among pediatric hospital emergency departments (ED) for evaluation of head injured children. We examined the rates of CT use by individual ED attending physicians for evaluation of head injured children in a pediatric hospital ED. METHODS We used an administrative database to identify children younger than 18 years evaluated for head injury from January 2011 through March 2013 at our children's hospital ED, staffed by pediatric emergency medicine (PEM) fellowship trained physicians and pediatricians. We excluded encounters with trauma team activation or previous head CT performed elsewhere. We excluded physicians whose patient volume was less than 1 standard deviation below the group mean. RESULTS After exclusions, we evaluated 5340 encounters for head injury by 27 ED attending physicians. For individual physicians, CT rates ranged from 12.4% to 37.3%, with a mean group rate of 28.4%. Individual PEM physician CT rates ranged from 18.9% to 37.3%, versus 12.4% to 31.8% for pediatricians. Of the 1518 encounters in which CT was done, 128 (8.4%) had a traumatic brain injury on CT, and 125 (8.2%) had a simple skull fracture without traumatic brain injury on CT. Patient factors associated with CT use included age younger than 2 years, higher triage acuity, arrival time of 10:00 PM to 6:00 AM, hospital admission, and evaluation by a PEM physician. CONCLUSIONS Physicians at our pediatric hospital ED varied in the use of CT for the evaluation of head-injured children.
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Abstract
Pediatric emergency physicians must have a high clinical suspicion for atlantoaxial rotatory subluxation (AARS), particularly when a child presents with neck pain and an abnormal head posture without the ability to return to a neutral position. As shown in the neurosurgical literature, timely diagnosis and swift initiation of treatment have a greater chance of treatment success for the patient. However, timely treatment is complicated because torticollis can result from a variety of maladies, including: congenital abnormalities involving the C1-C2 joint or the surrounding supporting muscles and ligaments, central nervous system abnormalities, obstetric palsies from brachial plexus injuries, clavicle fractures, head and neck surgery, and infection. The treating pediatrician must discern the etiology of the underlying problem to determine both timing and treatment paradigms, which vary widely between these illnesses. We present a comprehensive review of AARS that is intended for pediatric emergency physicians. Management of AARS can vary widely bases on factors, such as duration of symptoms, as well as the patient's history. The goal of this review is to streamline the management paradigms and provide an inclusive review for pediatric emergency first responders.
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Hansen M, Meckler G, Lambert W, Dickinson C, Dickinson K, Guise JM. Paramedic assessment and treatment of upper airway obstruction in pediatric patients: an exploratory analysis by the Children's Safety Initiative-Emergency Medical Services. Am J Emerg Med 2016; 34:599-601. [PMID: 26818155 PMCID: PMC4799729 DOI: 10.1016/j.ajem.2015.12.082] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 12/01/2015] [Accepted: 12/28/2015] [Indexed: 10/22/2022] Open
Affiliation(s)
- Matthew Hansen
- Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, USA.
| | - Garth Meckler
- Division of Pediatric Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - William Lambert
- Department of Public Health & Preventive Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Caitlin Dickinson
- Department of Obstetrics & Gynecology, Oregon Heath & Science University, Portland, OR, USA
| | - Kathryn Dickinson
- Department of Obstetrics & Gynecology, Oregon Heath & Science University, Portland, OR, USA
| | - Jeanne-Marie Guise
- Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, USA; Department of Public Health & Preventive Medicine, Oregon Health & Science University, Portland, OR, USA; Department of Obstetrics & Gynecology, Oregon Heath & Science University, Portland, OR, USA; Department of Medical Informatics & Clinical Epidemiology, Oregon Heath & Science University, Portland, OR, USA
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Chamberlain JM, Teach SJ, Hayes KL, Badolato G, Goyal MK. Practice Pattern Variation in the Care of Children With Acute Asthma. Acad Emerg Med 2016; 23:166-70. [PMID: 26766222 DOI: 10.1111/acem.12857] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Revised: 07/30/2015] [Accepted: 08/24/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Pediatric asthma is a highly prevalent disease, affecting over 7 million U.S. children and accounting for 750,000 annual emergency department (ED) visits. Guidelines from the National Asthma Education and Prevention Program recommend limited use of chest radiography (CXR), complete blood counts (CBCs), and antibiotics when managing acute exacerbations of asthma. However, studies suggest frequent overutilization of these resources. The objective was to evaluate differences between pediatric and general EDs in rates of CXRs, CBCs, and use of antibiotics for pediatric asthma exacerbations. METHODS This was a repeated cross-sectional analysis of data from the National Hospital Ambulatory Medical Care Survey from 2000 through 2010 of CXR, CBCs, and antibiotics during ED visits for pediatric acute asthma exacerbations. Multivariable logistic regression was performed to identify differences in asthma management by ED type (pediatric vs. general) after adjusting for demographic covariates. RESULTS There were 3,313 observations, representing an estimated 10.9 million (95% confidence interval [CI] = 9.7 to 12.1 million) ED visits for acute asthma without bacterial coinfection. Of these, 17.4% occurred in pediatric EDs. Multivariable logistic regression revealed that visits to pediatric EDs were less likely to include CXRs (adjusted odds ratio [AOR] = 0.39; 95% CI = 0.25 to 0.60), CBCs (AOR = 0.42; 95% CI = 0.22 to 0.80), and antibiotics (AOR = 0.50; 95% CI = 0.31 to 0.82) after adjustment for race/ethnicity, triage level, academic ED, metropolitan statistical area, and geographic region. CONCLUSIONS There are substantial differences in diagnostic testing and antibiotic usage for management of acute exacerbations of asthma by ED type, suggesting potential resource overuse in general EDs. Future studies should focus on evaluating the effect of quality improvement efforts for ED asthma management.
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Affiliation(s)
- James M. Chamberlain
- Department of Emergency Medicine; Children's National Medical Center; The George Washington University; Washington DC
| | - Stephen J. Teach
- Department of Emergency Medicine; Children's National Medical Center; The George Washington University; Washington DC
| | - Katie L. Hayes
- Department of Emergency Medicine; Children's National Medical Center; The George Washington University; Washington DC
| | - Gia Badolato
- Department of Emergency Medicine; Children's National Medical Center; The George Washington University; Washington DC
| | - Monika K. Goyal
- Department of Emergency Medicine; Children's National Medical Center; The George Washington University; Washington DC
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Borland ML, Shepherd M. Quality in paediatric emergency medicine: Measurement and reporting. J Paediatr Child Health 2016; 52:131-6. [PMID: 27062615 DOI: 10.1111/jpc.13077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 07/12/2015] [Accepted: 07/30/2015] [Indexed: 11/29/2022]
Abstract
There is a clear demand for quality in the delivery of health care around the world; paediatric emergency medicine is no exception to this movement. It has been identified that gaps exist in the quality of acute care provided to children. Regulatory bodies in Australia and New Zealand are moving to mandate the implementation of quality targets and measures. Within the paediatric emergency department (ED), there is a lack of research into paediatric specific indicators. The existing literature regarding paediatric acute care quality measures has been recently summarised, and expert consensus has now been reported. It is clear that there is much work to be performed to generalise this work to ED. We review suggestions from the current literature relating to feasible indicators within the paediatric acute care setting. We propose options to develop a quality 'scorecard' that could be used to assist Australian and New Zealand EDs with quality measurement and benchmarking for their paediatric patients.
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Affiliation(s)
- Meredith L Borland
- Emergency Department, Princess Margaret Hospital, Perth, Western Australia, Australia.,Schools of Paediatric and Child Health, Western Australia, Australia.,Primary Aboriginal and Rural Healthcare, University of Western Australia, Perth, Western Australia, Australia
| | - Mike Shepherd
- Children's Emergency Department, Starship Children's Hospital.,Auckland District Health Board.,Department of Paediatrics, University of Auckland, Auckland, New Zealand
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Ralston SL, Garber MD, Rice-Conboy E, Mussman GM, Shadman KA, Walley SC, Nichols E. A Multicenter Collaborative to Reduce Unnecessary Care in Inpatient Bronchiolitis. Pediatrics 2016; 137:peds.2015-0851. [PMID: 26628731 DOI: 10.1542/peds.2015-0851] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/19/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Evidence-based Guidelines for acute viral bronchiolitis recommend primarily supportive care, but unnecessary care remains well documented. Published quality improvement work has been accomplished in children's hospitals, but little broad dissemination has been reported outside of those settings. We sought to use a voluntary collaborative strategy to disseminate best practices to reduce overuse of unnecessary care in children hospitalized for bronchiolitis in community settings. METHODS This project was a quality improvement collaborative consisting of monthly interactive webinars with online data collection and feedback. Data were collected by chart review for 2 bronchiolitis seasons, defined as January, February, and March of 2013 and 2014. Patients aged <24 months hospitalized for bronchiolitis and without chronic illness, prematurity, or intensive care use were included. Results were analyzed using run charting, analysis of means, and nonparametric statistics. RESULTS There were 21 participating hospitals contributing a total of 1869 chart reviews to the project, 995 preintervention and 874 postintervention. Mean use of any bronchodilator declined by 29% (P = .03) and doses per patient decreased 45% (P < .01). Mean use of any steroids declined by 68% (P < .01), and doses per patient decreased 35% (P = .04). Chest radiography use declined by 44% (P = .05). Length of stay decreased 5 hours (P < .01), and readmissions remained unchanged. CONCLUSIONS A voluntary collaborative was effective in reducing unnecessary care among a cohort of primarily community hospitals. Such a strategy may be generalizable to the settings where the majority of children are hospitalized in the United States.
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Affiliation(s)
| | - Matthew D Garber
- University of South Carolina School of Medicine, Columbia, South Carolina
| | | | - Grant M Mussman
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | - Elizabeth Nichols
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire
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Lee DR, Lee CH, Won YK, Suh DI, Roh EJ, Lee MH, Chung EH. Clinical characteristics of children and adolescents with croup and epiglottitis who visited 146 Emergency Departments in Korea. KOREAN JOURNAL OF PEDIATRICS 2015; 58:380-5. [PMID: 26576182 PMCID: PMC4644766 DOI: 10.3345/kjp.2015.58.10.380] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 10/10/2014] [Accepted: 11/07/2014] [Indexed: 11/27/2022]
Abstract
Purpose Croup is a common pediatric respiratory illness with symptoms of varying severity. Moreover, epiglottitis is a rare disease that can rapidly progress to life-threatening airway obstruction. Although the clinical course and treatments differ between croup and epiglottitis, they are difficult to differentiate on presentation. We aimed to compare the clinical characteristics of croup and epiglottitis in Emergency Department patients. Methods The 2012 National Emergency Department Information System database of 146 Korean Emergency Departments was used to investigate patients aged ≤18 years presenting with croup or epiglottitis. Results We analyzed 19,374 croup patients and 236 epiglottitis patients. The male:female sex ratios were 1.9:1 and 2.3:1 and mean ages were 2.2±2.0 and 5.6±5.8 years, respectively. The peak incidence of croup was observed in July and that of epiglottitis was observed in May. The hospitalization rate was lower in croup than in epiglottitis patients, and the proportion of patients treated in the intensive care unit was lower among croup patients. The 3 most common chief complaints in both croup and epiglottitis patients were cough, fever, and dyspnea. Epiglottitis patients experienced dyspnea, sore throat, and vomiting more often than croup patients (P<0.05). Conclusion Both groups had similar sex ratios, arrival times, 3 most common chief complaints, and 5 most common comorbidities. Epiglottitis patients had a lower incidence rate, higher mean age of onset, and higher hospitalization rate and experienced dyspnea, sore throat, and vomiting more often than croup patients. Our results may help in the differential diagnosis of croup and epiglottitis.
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Affiliation(s)
- Doo Ri Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Chang Hyu Lee
- Department of Pediatrics, National Medical Center, Seoul, Korea
| | - Youn Kyung Won
- Department of Pediatrics, National Medical Center, Seoul, Korea
| | - Dong In Suh
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Eui-Jung Roh
- Department of Pediatrics, Sun General Hospital, Daejeon, Korea
| | - Mi-Hee Lee
- Department of Pediatrics, Incheon Medical Center, Incheon, Korea
| | - Eun Hee Chung
- Department of Pediatrics, National Medical Center, Seoul, Korea
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Jain S, Frank G, McCormick K, Wu B, Johnson BA. Impact of Physician Scorecards on Emergency Department Resource Use, Quality, and Efficiency. Pediatrics 2015; 136:e670-9. [PMID: 26260722 DOI: 10.1542/peds.2014-2363] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/06/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Variability in practice patterns and resource use in the emergency department (ED) can affect costs without affecting outcomes. ED quality measures have not included resource use in relation to ED outcomes and efficiency. Our objectives were to develop a tool for comprehensive physician feedback on practice patterns relative to peers and to study its impact on resource use, quality, and efficiency. METHODS We evaluated condition-specific resource use (laboratory tests; imaging; antibiotics, intravenous fluids, and ondansetron; admission) by physicians at 2 tertiary pediatric EDs for 4 common conditions (fever, head injury, respiratory illness, gastroenteritis). Resources used, ED length of stay (efficiency measure), and 72-hour return to ED (return rate [RR]) (balancing measure) were reported on scorecards with boxplots showing physicians their practice relative to peers. Quarterly scorecards were distributed for baseline (preintervention, July 2009-August 2010) and postintervention (September 2010-December 2011). Preintervention, postintervention, and trend analyses were performed. RESULTS In 51 450 patient visits (24 834 preintervention, 26 616 postintervention) seen by 96 physicians, we observed reduced postintervention use of abdominal and pelvic and head computed tomography scans, chest radiographs, intravenous antibiotics, and ondansetron (P < .01 for all). Hospital admissions decreased from 7.4% to 6.7% (P = .002), length of stay from 112 to 108 minutes (P < .001), and RR from 2.2% to 2.0%. Trends for use of laboratory tests and intravenous antibiotics showed significant reduction (P < .001 and P < .05, respectively); admission trends increased, and trends for use of computed tomography scans and plain abdominal radiographs showed no change. CONCLUSIONS Physician feedback on practice patterns relative to peers results in reduction in resource use for several common ED conditions without adversely affecting ED efficiency or quality of care.
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Affiliation(s)
- Shabnam Jain
- Department of Pediatrics and Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta, Atlanta, Georgia; and
| | - Gary Frank
- Children's Healthcare of Atlanta, Atlanta, Georgia; and
| | - Kelly McCormick
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Baohua Wu
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Brent A Johnson
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia
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Does active dissemination of evidence result in faster knowledge transfer than passive diffusion?: An analysis of trends of the management of pediatric asthma and croup in US emergency departments from 1995 to 2009. Pediatr Emerg Care 2015; 31:190-6. [PMID: 24694945 DOI: 10.1097/pec.0000000000000099] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE This study aimed to compare knowledge transfer (KT) in the emergency department (ED) management of pediatric asthma and croup by measuring trends in corticosteroid use for both conditions in EDs. METHODS A retrospective, cross-sectional study of the National Hospital Ambulatory Medical Care Survey data between 1995 and 2009 of corticosteroid use at ED visits for asthma or croup was conducted. Odds ratios (OR) were calculated using logistic regression. Trends over time were compared using an interaction term between disease and year and were adjusted for all other covariates in the model. We included children aged 2 to 18 years with asthma who received albuterol and were triaged emergent/urgent. Children aged between 3 months to 6 years with croup were included. The main outcome measure was the administration of corticosteroids in the ED or as a prescription at the ED visit. RESULTS The corticosteroid use in asthma visits increased from 44% to 67% and from 32% to 56% for croup. After adjusting for patient and hospital factors, this trend was significant both for asthma (OR, 1.07; 95% confidence interval [CI], 1.04-1.10) and croup (OR, 1.07; 95% CI, 1.03-1.12). There was no statistical difference between the 2 trends (P = 0.69). Hospital location in a metropolitan statistical area was associated with increased corticosteroid use in asthma (OR, 1.76; 95% CI, 1.10-2.82). Factors including sex, ethnicity, insurance, or region of the country were not significantly associated with corticosteroid use. CONCLUSIONS During a 15-year period, knowledge transfer by passive diffusion or active guideline dissemination resulted in similar trends of corticosteroid use for the management of pediatric asthma and croup.
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Ralston S, Comick A, Nichols E, Parker D, Lanter P. Effectiveness of quality improvement in hospitalization for bronchiolitis: a systematic review. Pediatrics 2014; 134:571-81. [PMID: 25092947 DOI: 10.1542/peds.2014-1036] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Bronchiolitis causes nearly 20% of all acute care hospitalizations for young children in the United States. Unnecessary testing and medication for infants with bronchiolitis contribute to cost without improving outcomes. OBJECTIVES The goal of this study was to systematically review the quality improvement (QI) literature on inpatient bronchiolitis and to propose benchmarks for reducing unnecessary care. METHODS Assisted by a medical librarian, we searched Medline, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library. Studies describing any active QI intervention versus usual care in hospitalized children <2 years of age were included. Data were extracted and confirmed by multiple investigators and pooled by using a random effects model. Benchmarks were calculated by using achievable benchmarks of care methods. RESULTS Fourteen studies involving >12000 infants were reviewed. QI interventions resulted in 16 fewer patients exposed to repeated doses of bronchodilators per 100 hospitalized (7 studies) (risk difference: 0.16 [95% confidence interval: 0.11-0.21]) and resulted in 5.3 fewer doses of bronchodilator given per patient (95% confidence interval: 2.1-8.4). Interventions resulted in fewer hospitalized children exposed to steroids (5 per 100), chest radiography (9 per 100), and antibiotics (4 per 100). No significant harms were reported. Benchmarks derived from the reported data are: repeated bronchodilator use, 16%; steroid use, 1%; chest radiography use, 42%; and antibiotic use, 17%. The study's heterogeneity limited the ability to classify specific characteristics of effective QI interventions. CONCLUSIONS QI strategies have been demonstrated to achieve lower rates of unnecessary care in children hospitalized with viral bronchiolitis than are the norm.
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Affiliation(s)
- Shawn Ralston
- Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; and The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire
| | - Allison Comick
- Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire
| | - Elizabeth Nichols
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire
| | - Devin Parker
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire
| | - Patricia Lanter
- Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; and The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire
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Abstract
PURPOSE OF REVIEW Bronchiolitis is a common condition in children less than 2 years of age and is a leading cause of infant hospitalization. Although there is significant variability in testing and treatment of children with bronchiolitis, diagnostic testing rarely improves care, and no currently available pharmacologic options have been proven to provide meaningful benefits or improve outcomes. RECENT FINDINGS Beta-agonists continue to be used frequently despite evidence that they do not reduce hospital admissions or length of stay. In general, therapies initially considered promising were subsequently proven ineffective, a pattern seen in studies on corticosteroids, and more recently with nebulized racemic epinephrine and hypertonic saline. Recent research has improved our understanding of the viral epidemiology of bronchiolitis, with increasing recognition of viruses other than respiratory syncytial virus and better awareness of the role of viral coinfections. How these findings will translate into improved outcomes remains uncertain. SUMMARY Much of the emphasis of the last few decades of bronchiolitis clinical care and research has centered on the identification and testing of novel therapies. Future quality improvement efforts should focus more on the limitation of unnecessary testing and treatments. Future research should include identification of subgroups of children with bronchiolitis that may benefit from focused clinical interventions.
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Affiliation(s)
- Alan R. Schroeder
- Department of Pediatrics, Santa Clara Valley Medical Center, San Jose, CA
| | - Jonathan M. Mansbach
- Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
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Affiliation(s)
- Mark I Neuman
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts 02115, USA.
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