Opportunistic urine ligase chain reaction screening for sexually transmitted diseases in adolescents seeking care in an urban emergency department

STUDY OBJECTIVE

Neisseria gonorrhoeae and Chlamydia trachomatis are the most common bacterial sexually transmitted diseases (STDs) in sexually active youth and many infections are asymptomatic or unrecognized. This study used ligase chain reaction assays for determination of prevalence of gonococcal and chlamydial infections in adolescents seeking care at an urban emergency department.

METHODS

An unlinked prevalence study was performed with ligase chain reaction tests on voided urine specimens from a convenience sample of adolescents 14 years or older who sought care at the Children's Hospital of Alabama ED. Demographic data and data on care provided in the ED were determined from retrospective chart review of those patients whose urine specimens were tested.

RESULTS

Of 282 urine specimens screened, 13.5% (38) yielded positive findings on ligase chain reaction testing for either or both pathogens (20 [7%] positive for N gonorrhoeae, 23 [8%] positive for C trachomatis). In the context of acute care, gonorrhea or chlamydial infection was diagnosed in 5 (1.8%). STD prevalence did not vary significantly by age. Only 39% (15/38) of patients with infections detected by ligase chain reaction testing received potentially effective antibiotics as a result of their urgent care evaluation.

CONCLUSION

Many adolescents use the ED for nonurgent care and unsuspected STDs are often missed. Urine ligase chain reaction testing is a sensitive, noninvasive means of detecting STDs by which unsuspected adolescent STD cases can be detected in an ED setting.

Evaluation of emergency department referrals by telephone triage

OBJECTIVE

Telephone triage programs are becoming very common at children's hospitals across the nation. One of the proposed benefits of these programs is the more efficient use of health care resources by triaging patients to the appropriate level of health care. The purpose of this study is to examine the appropriateness of referrals to a pediatric emergency department (ED) by the Pediatric Health Information Line (PHIL), a hospital-based telephone triage program, versus all other sources of referrals.

METHODS

A blinded Delphi rating system was used to review the physician's sheets of 133 consecutive ED referrals by PHIL for medical appropriateness. A total of 260 randomly selected control patients seen in the ED during the same period were similarly reviewed. If 2 of 3 pediatric emergency medicine physicians agreed that an ED visit was appropriate, then it was considered appropriate. A comparison of the 2 groups' ED appropriateness was made using a contingency table chi(2) test. An odds ratio with confidence limits was also calculated. Demographic data were collected for both groups including age, race, gender, and insurance status.

RESULTS

The PHIL group had an appropriateness rate of 80.2%, compared with 60.5% for the control group (chi(2) = 14.6369; odds ratio = 2.65; 95% confidence interval [1.5759,4.5008]).

CONCLUSIONS

This demonstrated that for the period studied, PHIL referrals to the ED had a 33% higher rate of appropriateness than controls. This evidence supports telephone triage as an efficient gatekeeper for health care resources.

Pediatric emergency department nurses' perspectives on fever in children

BACKGROUND

Fever is the most common complaint of children seen in a Pediatric Emergency Department (PED). Since pediatric emergency nurses commonly educate parents on fever management, this study sought to examine their knowledge base regarding fever in children.

METHODS

Through convenience sampling, pediatric emergency registered nurses working at one of four PEDs were surveyed using a self-administered questionnaire containing 10 open-ended questions pertaining to fever in children.

RESULTS

Eighty-eight pediatric emergency registered nurses (median experience 8.0 years, range 3 months to 28 years) were surveyed. The median temperature considered by pediatric emergency nurses to be a fever was 38.0 degrees C (100.4 degrees F) with a range of 37.2 degrees C (99.0 degrees F) to 38.9 degrees C (102.0 degrees F), while the median temperature considered to be dangerous to a child was 40.6 degrees C (105.0 degrees F) with a range of 38.0 degrees C (100.4 degrees F) to 41.8 degrees C (107.0 degrees F). Eleven percent was not sure what temperature constituted a fever while 31% was not sure what temperature would be dangerous to a child. Fifty-seven percent considered seizures the primary danger to a febrile child while 29% stated permanent brain injury or death could occur from a high fever. Sixty percent chose acetaminophen as first line treatment while 7% stated alcohol or tepid water baths were also acceptable treatment options. Thirty-eight percent stated that a different medication should be added if a child was still febrile 1 hour after initial treatment while 31% would not use additional medication. Eighteen percent stated it was dangerous for a child to leave the PED if still febrile.

CONCLUSION

Fever phobia and inconsistent treatment approaches occur among experienced pediatric emergency registered nurses. These phobias and inconsistencies subsequently could be conveyed to parents. In order to assure accurate parental education, PEDs should educate their medical team regarding the management of fever in children.

Effect of ketorolac in pediatric sickle cell vaso-occlusive pain crisis

BACKGROUND

Ketorolac is a parenteral, nonsteroidal analgesic that does not have a narcotic's risks of respiratory depression, hypotension, or dependence. Its usefulness in providing pain relief in pediatric patients with acute vaso-occlusive crisis of sickle cell disease has not been studied to date.

METHODS

Twenty-nine patients with sickle cell disease between the ages of 5 and 18 years who presented to The Children's Hospital of Alabama emergency department (ED) with 41 distinct episodes of acute vaso-occlusive pain crisis were enrolled prospectively and randomized to receive either 0.9 mg/kg intravenous (IV) ketorolac or placebo in a double-blind fashion. All patients also received IV fluids and an initial 0.1 mg/kg of IV morphine. Subsequent standardized doses of morphine were given every 2 hours over a 6-hour observation period based upon severity of pain as scored by a 10-cm linear visual analog scale (VAS). Vital signs and pain severity were recorded initially and assessed hourly. Disposition was made at the end of the observation period.

RESULTS

Patients receiving ketorolac and those receiving placebo were of similar age, weight, gender, number of prior ED visits, number of prior hospital admissions, duration of pain prior to presentation, and initial pain score. The total dose of morphine received, reduction in severity of pain as measured by VAS, rate of hospital admission, and rate of return to the ED for discharged patients did not differ significantly between the two groups.

CONCLUSION

We were unable to demonstrate a synergistic analgesic effect for ketorolac in the treatment of pain from acute vaso-occlusive crisis in pediatric sickle cell disease. Further investigations involving larger samples of sickle cell patients may be needed to further define a role for ketorolac in the acute management of sickle cell vaso-occlusive pain.

Use of PRISM scores in triage of pediatric patients with diabetic ketoacidosis

Triage guidelines are needed to help in the decision process of intensive care unit (ICU) versus non-ICU admission for patients with diabetic ketoacidosis (DKA). Pediatric risk of mortality (PRISM) scores have long been used to assess mortality risk. This study assess the usefulness of the traditional PRISM score and adaptation of that score (PRISM-ED, which uses presentation data only) in predicting hospital stay in pediatric patients with DKA. PRISM and PRISM-ED were tested for correlation with length of stay and length of ICU stay. A medical record review was conducted for patients admitted to The Children's Hospital of Alabama with DKA during an 18-month period (n = 79). Two scores were calculated for each study entrant: PRISM using the worst recorded values over the first 24 hours and PRISM-ED using arrival values. Median scores, median test, and Spearman rank correlations were determined for both tests. Median PRISM scores were PRISM = 11 and PRISM-ED = 12; Median PRISM and PRISM-ED scores for patients admitted to the ICU were less than median scores among floor-admitted patients: [table: see text] Spearman rank correlations were significant for both scores versus total stay: PRISM, rs = 0.29; P = 0.009; PRISM-ED, rs = 0.60, P < 0.001. Also, correlations were significant for both scores versus ICU stay: PRISM rs = 0.22, P = 0.05; PRISM-ED, rs = 0.41, P < 0.001. Triage guidelines for ICU versus floor admission for DKA patients could have significant economic impact (mean ICU charge = $11,417; mean charge for floor admission = $4,447). PRISM scores may be an important variable to include in a multiple regression model used to predict the need for ICU monitoring.