Children accessing accident and emergency department for non-urgent consultations: A cross-sectional study about parents' use of primary care services

INTRODUCTION

Parents often take their children to the Paediatric Accident and Emergency Department (A&E) for non-urgent consultations rather than using community-based primary care services. This study describes the use of primary care services in parents taking their children to the A&E for non-urgent consultations.

METHODS

A cross-sectional study was conducted from July 2018 to June 2019, in a second-level Italian paediatric A&E of a tertiary-level children's academic research and hub hospital. Parents of children aged between 3 months and 6 years assigned with a white code at the triage were asked to complete a paper-and-pencil 40-item questionnaire after accessing the A&E for a non-urgent consultation.

RESULTS

The questionnaire was completed by the parents of 237 children (males 58 %; median age = 2.3 years). Overall, 48.1 % (n = 114) of the parents reported consulting 'often/always' the primary care paediatrician, mainly when their child was sick and for check-ups (n = 182, 76.8 %). However, only 7.2 % (n = 17) of the parents 'often/always' used any other health service in the community. Most of them (n = 191, 82 %) did not even know where the community health centre was located.

CONCLUSION

Parents accessing the A&E for non-urgent consultations should be better informed/educated on how to use community health services.

A Cell-Phone Medication Error eHealth App for Managing Safety in Chronically Ill Young Patients at Home: A Prospective Study

Introduction: Whereas ample information describes medication errors (MEs) in children or in mixed pediatric and adult populations discharged with acute or chronic diseases from hospital to community settings, little is known about MEs in children and adolescents with chronic diseases discharged home, a major concern. To promote home medication safety, we trained parents of children discharged with chronic diseases to record ME with a tailored cell-phone eHealth app. Methods: In a 1-year prospective study, we used the app to monitor ME in patients with chronic diseases discharged home from a tertiary hospital in Rome, Italy. Univariate and multivariate analyses detected the ME incidence rate ratio (IRR). Results: Of the 310 parents enrolled, 194 used the app. The 41 MEs involved all drug management phases. The ME IRR was 0.46 errors per child. Children <1 year had the highest ME risk (1.69 vs. 0.35, p = 0.002). Children discharged from the cardiology unit had a statistically higher ME IRR than others (3.66, 95% confidence interval: 1.01-13.23%). Conclusions: The highest ME risk at home involves children with chronic diseases <1 year old. A significant ME IRR at home concerns children with heart diseases of any age. Parents find a tailored eHealth app for monitoring and reporting ME at home easy to use. At discharge, clinical teams need to identify age-related and disease-residual risks to target additional actions for monitoring ME, thus increasing medication safety at home.

Early recognition of child abuse through screening indicators at the emergency department: experience of a tertiary urban pediatric hospital

Background

Emergency Departments play a pivotal role in detecting cases of child abuse. Despite the efforts made in the past decades on the need for a screening method for the early detection of abuse victims, a unique instrument shared by the international scientific community has not been made. These instruments should be able to help recognizing whether it is necessary to further investigate the child’s condition. The aim of the study is to illustrate the screening indicators in use since 2010 in the Emergency Department of the Bambino Gesù Children’s Hospital to early recognise the victims of abuse and the modifying process of the screening tool undertaken over the years.

Methods

We retrospectively analyzed the process that led to the editing of the indicators of child abuse in use nowadays at the Bambino Gesù Children's Hospital. We codified three clinical pathways to apply in case of suspected abuse. Furthermore, we investigated the medical records of screening-positive accesses in the Paediatric Emergency Department of the Bambino Gesù Children's Hospital from January 2008 to October 2020.

Results

An estimation of positive screening, regarding the type of abuse suspected, and the number of accessed in ED was made, resulting in a cohort of 956 patients. In 2010 we created a list of 14 items grouped in three clusters: anamnestic declarations or incongruences, carelessness/neglect and evident lesions at physical examination. Positivity to one of the items allows the actuation of the investigating protocol named as clinical pathway.In 2013, after three years of experience, the criteria were edited to increase specificity. The application of screening led to a median number of 82 suspected cases/year from 2013 to 2020.

Conclusion

A screening tool is essential and productive for the early recognition of victims of abuse. An in-deep analysis of suspected cases through a standardized method, such as the clinical pathway, allowed reaching the diagnosis in a more accurate and precise manner.

Pediatric patients accessing Accident and Emergency Department (A&E) for non-urgent treatment: Why do parents take their children to the A&E?

INTRODUCTION

About 20-30% of children access the Pediatric Accident and Emergency Department (A&E) for non-urgent health care that should normally follow other health care paths. This study aimed to investigate why parents take their children to the A&E for non-urgent visits rather than using primary care services.

METHODS

A one-year cross-sectional study was conducted in a large pediatric A&E in Italy. A paper-and-pencil 40-item questionnaire was administered to parents of children aged between 3 months to 6 years who accessed the A&E for non-urgent visits between July 2018 and June 2019.

RESULTS

Parents of 238 children completed the questionnaire (mean age = 2.6 years; male 58%). The most common symptoms were fever (n = 105; 44.1%) and skin rash (n = 63; 26.5%); symptoms usually started more than 24 h earlier (n = 163; 69.4%). Reasons for accessing the A&E for non-urgent visits included the availability of rapid medical tests (n = 71; 29.8%), deterioration of the clinical conditions after the pediatrician's visit (n = 67; 28.2%), and the perceived need for urgent care (n = 65; 27.3%). Besides, 26.6% (n = 63) of parents reported not being able to contact their pediatrician before accessing A&E.

CONCLUSION

Parents may need further education to distinguish between urgent and non-urgent pediatric health conditions.

Using an App to monitor postoperative pain at home in pediatric patients

A prospective comparative study was conducted in 487 pediatric patients (69% male, mean age = 6.4 ± 4.0) to evaluate (a) the incidence, intensity, and characteristics of pain in pediatric patients at home during the first 24 hours and 5 days after surgery and (b) the factors associated with higher pain intensity, including the impact of an application (App) compared to the paper-and-pencil approach. Postoperative pain was assessed by patients or their parents at home using the 'Bambino Gesù' Children's Hospital (Ospedale Pediatrico Bambino Gesù, OPBG) tool for participants aged 4-17 years or the Faces, Legs, Arms, Cry, and Consolability scale for participants less than four years old. Participants were assigned to two groups: those who used the paper-and-pencil version of the pain scale and those who used the App. Overall, 209 of the 472 (44%) participants reported pain during the first 24 hours, and 92 of the 420 (22%) reported pain between one and five days after surgery. Higher pain intensity scores were associated with being in the App group, directly assessing own pain, and using the OPBG tool. The App was effective in facilitating pain assessment. Health professionals could empower pediatric patients and their parents in assessing pain at home through a dedicated App.

New Rules on Patient's Safety and Professional Liability for the Italian Health Service

BACKGROUND

The phenomenon of clinical negligence claims has rapidly spread to United States, Canada and Europe assuming the dimensions and the severity of a pandemia. Consequently, the issues related to medical malpractice need to be studied from a transnational perspective since they raise similar problems in different legal systems.

METHODS

Over the last two decades, medical liability has become a prominent issue in healthcare policy and a major concern for healthcare economics in Italy. The failures of the liability system and the high cost of healthcare have led to considerable legislative activity concerning medical malpractice liability, and a law was enacted in 2012 (Law no. 189/2012), known as the "Balduzzi Law".

RESULTS

The law tackles the mounting concern over litigation related to medical malpractice and calls for Italian physicians to follow guidelines. Briefly, the law provided for the decriminalisation of simple negligence of a physician on condition that he/she followed the guidelines and "good medical practice" while carrying out his/her duties, whilst the obligation for compensation, as defined by the Italian Civil Code, remained. Judges had to consider that the physician followed the provisions of the guidelines but nevertheless caused injury to the patient.

CONCLUSION

However, since the emission of the law, thorny questions remain which have attracted renewed interest and criticism both in the Italian courts and legal literature. Since then, several bills have been presented on the topic and these have been merged into a single text entitled "Regulations for healthcare and patient safety and for the professional responsibility of healthcare providers".

Improve Healthcare Quality Through Mortality Committee: Retrospective Analysis of Bambino Gesù Children Hospital's Ten Years' Experience 2008-2017

BACKGROUND

Healthcare quality improvements are one of the most important goals to reach a better and safer healthcare system. Reviewing in-hospital mortality data is useful to identify areas for improvement, and to monitor the impact of actions taken to avoid preventable cases, such as those related to healthcare associated infections (HAI).

METHODS

In this paper, we present the experience of the Mortality Committee of Bambino Gesù Children Hospital (OPBG). OPBG has instituted a process of systematic revision of all in-hospital deaths conducted by a multidisciplinary team. The goal is to identify system-wide issues that could be improved to reduce in-hospital preventable deaths. In this way, the mortality review goes alongside all the other risk management activities for the continuous quality improvement and patient safety.

RESULTS

In years 2008-2017, we performed a systematic analysis of 1148 inpatient deaths. In this time period, the overall mortality rate was 0.4%. Forty-seven deaths were caused due to infections, 10 of which involved patients with HAI transferred to OPBG from other facilities or patients with community- acquired infections. Six deaths related to HAI were followed by claims compensations. All these cases were not followed by compensation because the onset of HAI was considered an inevitable consequence of the underlying disease.

CONCLUSION

Introduction of the mortality review committee has proved to be a valid instrument to improve the quality of the care provided in a hospital, allowing early identification of care gaps that could lead to an increase in mortality rates. Article Highlights Box: Reduction of preventable deaths is one of the most important goals to be achieved for any health-care system and to improve the quality of care. • Several studies have shown that analysis of morbidity and mortality rate helps to detect any factors that can lead to an increase in in-hospital mortality rates. • The review of in-hospital deaths allows to learn how to improve the quality and safety of care through identification of critical issues that lead to an increase in mortality ratio. • In some medical areas, such as intensive care units or surgery, the implementation of the conference on mortality and morbidity is more useful for assessing procedures at high risk of errors. • The implementation of existing databases with data deriving from the systematic review of medical records and in-hospital deaths appears to be desirable. • Mortality Review Committees can represent a very useful tool for all the health facilities for the reduction of preventable deaths, such as those related to HAI.

[Paediatric patients who access the Emergency Department for non-urgent visits and use of community services]

. Paediatric patients who access the Emergency Department for non-urgent visits and use of community services.

INTRODUCTION

Overcrowding in emergency departments, often due to the high number of patients who access for non-urgent visits, leads to serious problems concerning also the quality of care.

AIM

To investigate if and how parents who access a second level Emergency Department for non-urgent pediatric visits use community services.

METHODS

From 11 July to 16 September 2018 a 40-item paper and pencil questionnaire was administered to parents of children aged 0 to 6 years who received a non-urgent code for access to the Emergency Department.

RESULTS

Parents of 83 patients (males=62.7%, mean age=2 years±1.77) were enrolled. Most of them accessed the emergency departments because of their child's fever (n=31, 21.8%), for symptoms occurred more than 24 hours before (n=51, 61.4%). Most participants reported to consult sometimes/always the family pediatrician (n=72, 86.8%) but to hardly ever/never use the other health services available in the community. Parents need to receive more education regarding the management on the most typical symptoms in children, such as fever and skin rashes, or some minor frequent treatments.

CONCLUSIONS

Parents who access the Emergency Department for non-urgent visits rarely use or know the community health services, which could help them in managing their child's health conditions.

Qualitative study exploring factors influencing escalation of care of deteriorating children in a children's hospital

BACKGROUND

System-level interventions including rapid response teams and paediatric early warning scores have been designed to support escalation of care and prevent severe adverse events in hospital wards. Barriers and facilitators to escalation of care have been rarely explored in paediatric settings.

AIM

This study explores the experiences of parents and healthcare professionals of in-hospital paediatric clinical deterioration events to identify factors associated with escalation of care.

METHODS

Across 2 hospital sites, 6 focus groups with 32 participants were conducted with parents (n=9) and healthcare professionals (n=23) who had cared for or witnessed a clinical deterioration event of a child. Transcripts of audio recording were analysed for emergent themes using a constant comparative approach.

FINDINGS

Four themes and 19 subthemes were identified: (1) impact of staff competencies and skills, including personal judgement of clinical efficacy (self-efficacy), differences in staff training and their impact on perceived nursing credibility; (2) impact of relationships in care focusing on communication and teamwork; (3) processes identifying and responding to clinical deterioration, such as patient assessment practices, tools to support the identification of patients at risk and the role of the rapid response team; and (4) influences of organisational factors on escalation of care, such as staffing, patient pathways and continuity of care.

CONCLUSIONS

Findings emphasise the considerable influence of social processes such as teamwork, communication, models of staff organisation and staff education. Further studies are needed to better understand how modification of these factors can be used to improve patient safety.

An unusual death by propranolol ingestion

A case of acute intoxication with propranolol is reported. A 60-year-old man was found dead in his car with no evidence of trauma or signs of asphyxia. Near the car, a pharmaceutical box of Inderal, a pharmaceutical formulation containing propranolol, was found. The man was not under therapy with this medication, but circumstantial data suggested the use of this medicine by his sister. High blood levels of propranolol confirmed the suspected drug use and induced us to discuss the probable lethal mechanism of this substance. The analysis of this compound was performed by liquid-liquid extraction followed by gas chromatography/mass spectrometry determination.

Application of hair analysis to document coercive heroin administration to a child

This paper describes the application of hair analysis in a judicial case to document coercive heroin administration to a 5-year-old child, who was admitted with overdose symptoms to an intensive care division. Segmental hair analysis was performed in order to determine if drug consumption had continued. Quantitative results showed the presence of morphine and O-6-monoacetylmorphine (MAM) in increasing amounts from the second to the distal segment of hair, each approximately corresponding to a period of time of one month. MAM concentrations ranged from 0.2 ng/mg in the second segment of hair to 0.6 ng/mg in the distal segment; morphine concentrations ranged from 0.1 to 0.3 ng/mg. Limits of detection were 0.1 ng/mg for morphine and 0.2 ng/mg for MAM. The proximal segment of hair, which corresponded to the period that the child was housed in a social center, was negative for opiates.

Evaluation of cocaine use during pregnancy through toxicological analysis of hair

Toxicological analysis of hair was used to detect cocaine use in a group of 615 pregnant women. Hair samples were washed, enzymatically digested, and analyzed by radioimmunoassay for cocaine. Positive results were confirmed by gas chromatography-mass spectrometry after a solid-phase extraction. Benzoylecgonine (BZE) and cocaine were detected after derivatization with pentafluoropropionic-anhydride-pentafluoropropanol. Deuterated cocaine and BZE were used as internal standards. This study demonstrated a mean frequency of 1.9% cases positive for cocaine in all the hair samples examined. The positive rate was 6% among women admitted for spontaneous abortion (66 cases), and the positive rate was 1.4% for those who carried to full term (549 cases). These data underline the usefulness of hair analysis for the diagnosis of drug abuse and demonstrate that there is significant use of cocaine in the Italian population.

Cocaine during pregnancy: a critical review of the literature

A number of epidemiological indices suggest that the use of cocaine in Italy is increasing, thus explaining the importance of scientific interest in this field. There is considerable disparity between the scientific papers published in the literature concerning the damaging effects on fetus and mother linked to the use of cocaine during pregnancy. The main problem consists of the method used to identify those patients using cocaine. These methods are burdened by a high level of false negatives: subjects who often use a variety of active pharmacological substances are identified and the methods are not always suitable for classifying subjects according to useful clinical parameters. This is reflected in the poor quality of data concerning the epidemiology and clinical aspects of cocaine abuse during pregnancy. A careful selection of the best scientific papers published in the literature shows that the effects on the maternal organism are slight, whereas those on the fetus are more severe. Compared to controls, the use of cocaine is associated with a high percentage of cardiac malformations, preterm delivery, low birth weight and minor anomalies of the nervous system. Results relating to sudden neonatal death are discordant. This paper shows that the use of cocaine is often underestimated both in epidemiological terms and from the fetal point of view. This behaviour is linked to the belief that the effects of cocaine are benign.

Drug distribution in the head, axillary and pubic hair of chronic addicts

This study investigates the distribution of some drugs in hair samples taken from different parts of the body (head, pubis and axillae). Samples drawn from 15 subjects who died from drug overdose were analysed. The concentrations of the drugs detected in the biological fluids did not appear to be correlated with those present in hair. The highest drug levels were observed in pubic hair. The concentration differences observed in the various types of hair can hypothetically be ascribed to a likely incorporation of the drugs from the outside.

Improved enzymatic hydrolysis of hair

An enzymatic hair extraction method is proposed for drug analysis. Pronase digestion of various aliquots of hair from a cocaine abuser was preceded by a 2-h incubation with a dithiothreitol solution. The extraction solution was tested to identify possible interferences in the radioimmunoassay and was compared with other hydrolysis methods to assess the results of extraction.

Fatal case of bamifylline intoxication

The case of a young woman who committed suicide by oral ingestion of a large amount of bamifylline is reported. The absence of significant pathological findings, together with high blood levels of the drug, have induced us to discuss the probable lethal mechanisms of this substance currently regarded as a safe drug.

Drugs in hair: a new extraction procedure

An enzymatic hydrolysis of hair for drug detection is described. The results obtained with the suggested method are compared with those observed by chemical hydrolysis. Enzymatic digestion provides a high recovery (80%) for cocaine metabolite, while alkaline hydrolysis causes its chemical destruction. The two hydrolytic procedures yielded comparable results for morphine. The outlined procedure is recommended when unstable compounds are to be detected in hair.

Methadone extraction from minimal amounts of biological fluids

A new solid phase extraction method was studied to extract methadone from small amounts of biological samples, by using little disposable columns prepacked with reverse phase sorbents. Two different commercial kinds of reversed phase columns prepacked with octadecylsilane (ODS) were tested; the results were compared to those obtained by a direct liquid/liquid extraction method. Gas chromatograms of extracts obtained by means of ODS reversed phase columns showed a good signal/noise ratio resulting in higher sensitivity (20 ng/ml as detection limit), in comparison with the liquid/liquid extraction method.

Methadone in pregnancy: clinical-toxicological aspects

The authors describe their experience with methadone treatment in pregnancy. Thirteen abuser pregnant women were studied under defined obstetrical and toxicological protocol. Newborns were also included in this study. In some cases a complete adherence to therapeutic program, allowing labour under very low methadone dosage (5 mg/day), minimized toxicological neonatal risk. Withdrawal syndrome in newborns was well controlled pharmacologically. The role of the toxicological laboratory during clinical management of drug dependent pregnant women is also discussed.