Characteristics of Febrile Children Admitted to the ICU Following an Unscheduled ED Revisit Within 72 h, a Case-Control Study

Return Visits in Infants Younger Than 90 Days Presenting to the Pediatric Emergency Department for Fever

Fever in infants presenting to pediatric emergency departments (PEDs) often results in significant return visits (RVs). This retrospective study aimed to identify factors associated with RVs in febrile infants aged 0 to 90 days. Data from infants presenting to PED between 2018 and 2021 and returning within 7 days (RV group) were compared to age-matched febrile infants without RVs (control group). Each group had 95 infants with similar demographics and medical history. RVs were primarily due to positive cultures and persistent fever. The control group had higher initial hospitalization rates, longer PED stays, and increased antibiotic treatment. Prevalence of serious bacterial infections (SBIs) did not significantly differ. Higher hospitalization, prolonged PED stays, and initial antibiotic treatment were associated with reduced RV incidence despite similar SBI rates. Return visits in infants <90 days were primarily driven by persistent fever and positive cultures. Addressing these factors through targeted parental education and improved care protocols may reduce RVs.

High-risk Return Visits to United States Emergency Departments, 2010–2018

Introduction: Although factors related to a return visit to the emergency department (ED) have been reported, only a few studies have examined “high-risk” ED revisits with serious adverse outcomes. In this study we aimed to describe the incidence and trend of high-risk ED revisits in United States EDs and to investigate factors associated with these revisits. Methods: We obtained data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), 2010–2018. Adult ED revisits within 72 hours of a previous discharge were identified using a mark on the patient record form. We defined high-risk revisits as revisits with serious adverse outcomes, including intensive care unit admissions, emergency surgery, cardiac catheterization, or cardiopulmonary resuscitation (CPR) during the return visit. We performed analyses using descriptive statistics and multivariable logistic regression, accounting for NHAMCS’s complex survey design. Results: Over the nine-year study period, there were an estimated 37,700,000 revisits, and the proportion of revisits in the entire ED population decreased slightly from 5.1% in 2010 to 4.5% in 2018 (P for trend = 0.02). By contrast, there were an estimated 827,000 high-risk ED revisits, and the proportion of high-risk revisits in the entire ED population remained stable at approximately 0.1%. The mean age of these high-risk revisit patients was 57 years, and 43% were men. Approximately 6% of the patients were intubated, and 13% received CPR. Most of them were hospitalized, and 2% died in the ED. Multivariable analysis showed that older age (65+ years), Hispanic ethnicity, daytime visits, and arrival by ambulance during the revisit were independent predictors of high-risk revisits. Conclusion: High-risk revisits accounted for a relatively small fraction (0.1%) of ED visits. Over the period of the NHAMCS survey between 2010-2018, this fraction remained stable. We identified factors during the return visit that could be used to label high-risk revisits for timely intervention.

C-Reactive Protein and the Outcome of a Pediatric Emergency Department 7 Days Revisit

BACKGROUND

Pediatric emergency department (PED) return visits represent an important quality of care metric and constitute a patient-centered outcome. C-reactive protein (CRP) is an inflammatory biomarker that is commonly used as screening tool in the PED. In this study, we assessed the clinical outcomes of children whose levels of CRP are 150 mg/L or higher at the initial PED visit and if such levels could be useful in predicting outcomes at a second PED visit.

METHODS

A historical cohort study of all patients who visited the PED between July 2007 and June 2017 and had a CRP value of 150 mg/L or greater in the setting of a febrile illness. Data of patients with a return visit to the PED within 7 days were assessed for an association between laboratory values, diagnosis and clinical outcome.

RESULTS

One hundred thirty-six index visits were included in this study. One hundred fifteen (84.6%) of the revisits were discharged after their second visit, and 21 (15.4%) were admitted to the inpatient unit. Admitted patients did not differ from patients who were discharged home in diagnosis and CRP levels, but a difference in white blood cell and absolute neutrophil counts was observed.

CONCLUSIONS

The intensity of the inflammatory response, as expressed by the high concentrations of CRP in children, does not seem to predict the outcome at a repeat PED visit within 7 days.

Risk Factors for Early Return Visits to the Emergency Department in Patients Presenting with Nonspecific Abdominal Pain and the Use of Computed Tomography Scan

Over a quarter of patients presenting with abdominal pain at emergency departments (EDs) are diagnosed with nonspecific abdominal pain (NSAP) at discharge. This study investigated the risk factors associated with return ED visits in Taiwanese patients with NSAP after discharge. We divided patients into two groups: the study group comprising patients with ED revisits after the index ED visit, and the control group comprising patients without revisits. During the study period, 10,341 patients discharged with the impression of NSAP after ED management. A regression analysis found that older age (OR [95%CI]: 1.007 [1.003–1.011], p = 0.004), male sex (OR [95%CI]: 1.307 [1.036–1.650], p = 0.024), and use of NSAIDs (OR [95%CI]: 1.563 [1.219–2.003], p < 0.001) and opioids (OR [95%CI]: 2.213 [1.643–2.930], p < 0.001) during the index visit were associated with increased return ED visits. Computed tomography (CT) scans (OR [95%CI]: 0.605 [0.390–0.937], p = 0.021) were associated with decreased ED returns, especially for those who were older than 60, who had an underlying disease, or who required pain control during the index ED visit.

Shock Index, Pediatric Age-Adjusted Predicts Morbidity and Mortality in Children Admitted to the Intensive Care Unit

Background: The shock index, pediatric age-adjusted (SIPA), defined as the maximum normal heart rate divided by the minimum normal systolic blood pressure by age, can help predict the risk of morbidity and mortality after pediatric trauma. This study investigated whether the SIPA can be used as an early index of prognosis for non-traumatic children visiting the pediatric emergency department (ED) and were directly admitted to the intensive care unit (ICU). We hypothesized that an increase in SIPA values in the first 24 h of ICU admission would correlate with mortality and adverse outcomes. Methods: This multicenter retrospective study enrolled non-traumatic patients aged 1-17 years who presented to the pediatric ED and were directly admitted to the ICU from January 1, 2016, to December 31, 2018, in Taiwan. The SIPA value was calculated at the time of arrival at the ED and 24 h after ICU admission. Cutoffs included SIPA values >1.2 (patient age: 1-6), >1.0 (patient age: 7-12), and >0.9 (patient age: 12-17). The utility of the SIPA and the trends in the SIPA during the first 24 h of ICU admission were analyzed to predict outcomes. Results: In total, 1,732 patients were included. Of these, 1,050 (60.6%) were under 6 years old, and the median Pediatric Risk of Mortality score was 7 (5-10). In total, 4.7% of the patients died, 12.9% received mechanical ventilator (MV) support, and 11.1% received inotropic support. The SIPA value at 24 h after admission was associated with increased mortality [odds ratio (OR): 4.366, 95% confidence interval (CI): 2.392-7.969, p < 0.001], MV support (OR: 1.826, 95% CI: 1.322-2.521, p < 0.001), inotropic support (OR: 2.306, 95% CI: 1.599-3.326, p < 0.001), and a long hospital length of stay (HLOS) (2.903 days, 95% CI: 1.734-4.271, p < 0.001). Persistent abnormal SIPA value was associated with increased mortality (OR: 2.799, 95% CI: 1.566-5.001, p = 0.001), MV support (OR: 1.457, 95% CI: 1.015-2.092, p = 0.041), inotropic support (OR: 1.875, 95% CI: 1.287-2.833, p = 0.001), and a long HLOS (3.2 days, 95% CI: 1.9-4.6, p < 0.001). Patients with abnormal to normal SIPA values were associated with decreased mortality (OR: 0.258, 95% CI: 0.106-0.627, p = 0.003), while patients with normal to abnormal SIPA values were associated with increased mortality (OR: 3.055, 95% CI: 1.472-5.930, p = 0.002). Conclusions: In non-traumatic children admitted to the ICU from the ED, increased SIPA values at 24 h after ICU admission predicted high mortality and bad outcomes. Monitoring the trends in the SIPA could help with prognostication and optimize early management.