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The article explores the agreement between electronic health record (EHR)-documented and parent-reported race and ethnicity in pediatric emergency care settings. It discusses significant overall agreement but notes discrepancies, particularly for less-represented racial and ethnic groups, suggesting the need for improved methods to enhance data accuracy and equity in healthcare research and provision.

OBJECTIVES: Undertriage, the underestimation of acuity, can result in delayed care and potential morbidity in the emergency department (ED). Although inequities in ED care based on language preference have been noted, little is known about its association with undertriage. We evaluated for differences in undertriage based on caregiver language preference. METHODS: This was a retrospective cross-sectional study of patients aged younger than 21 years, triaged as Emergency Severity Index (ESI) level 4 or 5 (nonurgent), to the pediatric ED from January 1, 2019, through January 31, 2021. Indicators of undertriage were defined as hospital admission, significant ED resource use, or return visits with admission. We used logistic regression with generalized estimating equations to measure the association of preferred language with undertriage. RESULTS: Of 114 266 ED visits included in the study, 22 525 (19.8%) represented patients with caregivers preferring languages other than English. These children were more likely to experience undertriage compared with those with caregivers preferring English (3.7% [English] versus 4.6% [Spanish] versus 5.9% [other languages]; Spanish versus English: odds ratio [OR], 1.3; 95% confidence interval [CI], 1.2-1.4] and other languages versus English: OR, 1.6; 95% CI, 1.2-2.2). Differences remained after adjusting for sex, insurance, mode of arrival, and clustering by triage nurse (Spanish versus English: adjusted OR, 1.3; 95% CI, 1.3-1.5) and other languages versus English: adjusted OR, 1.6; 95% CI, 1.2-2.2). CONCLUSIONS: Children accompanied by caregivers preferring languages other than English are more likely to be undertriaged in the pediatric ED. Efforts to improve the triage process are needed to promote equitable care for this population. [ABSTRACT FROM AUTHOR]

Objective: To determine if there was a clinically important difference (15 minutes or more) in length of stay (LOS) for low-acuity pediatric ED patients treated by PAs compared with those treated by pediatricians. Methods: Between July 2017 and February 2020, shifts were identified that had shared PA and pediatrician staffing in the low-acuity care area for a large, urban ED. LOS was collected for every patient during the 6 hours of overlap for each shift. Using a paired analysis, we calculated the difference in mean LOS for these shifts. Results: Mean shift LOS for children seen by PAs (160.1 minutes, SD: 48.6) was 10.1 minutes longer (95% CI: 6.1, 14.1) than mean shift LOS for children seen by pediatricians (150 minutes, SD: 47.3). Conclusions: No clinically important difference in LOS was found for low-acuity children treated by PAs compared with those treated by pediatricians in a large, urban ED. [ABSTRACT FROM AUTHOR]

Objectives: The diagnostic process is a vital component of safe and effective emergency department (ED) care. There are no standardized methods for identifying or reliably monitoring diagnostic errors in the ED, impeding efforts to enhance diagnostic safety. We sought to identify trigger concepts to screen ED records for diagnostic errors and describe how they can be used as a measurement strategy to identify and reduce preventable diagnostic harm. Methods: We conducted a literature review and surveyed ED directors to compile a list of potential electronic health record (EHR) trigger (e-triggers) and non-EHR based concepts. We convened a multidisciplinary expert panel to build consensus on trigger concepts to identify and reduce preventable diagnostic harm in the ED. Results: Six e-trigger and five non-EHR based concepts were selected by the expert panel. E-trigger concepts included: unscheduled ED return to ED resulting in hospital admission, death following ED visit, care escalation, high-risk conditions based on symptom-disease dyads, return visits with new diagnostic/therapeutic interventions, and change of treating service after admission. Non-EHR based signals included: cases from mortality/morbidity conferences, risk management/ safety office referrals, ED medical director case referrals, patient complaints, and radiology/laboratory misreads and callbacks. The panel suggested further refinements to aid future research in defining diagnostic error epidemiology in ED settings. Conclusions: We identified a set of e-trigger concepts and non-EHR based signals that could be developed further to screen ED visits for diagnostic safety events. With additional evaluation, trigger-based methods can be used as tools to monitor and improve ED diagnostic performance. [ABSTRACT FROM AUTHOR]

Objective To measure the variability in discharge opioid prescription practices for children discharged from the emergency department (ED) with a long-bone fracture. Design A retrospective cohort study of pediatric ED visits in 2015. Setting Four pediatric EDs. Subjects Children aged four to 18 years with a long-bone fracture discharged from the ED. Methods A multisite registry of electronic health record data (PECARN Registry) was analyzed to determine the proportion of children receiving an opioid prescription on ED discharge. Multivariable logistic regression was performed to determine characteristics associated with receipt of an opioid prescription. Results There were 5,916 visits with long-bone fractures; 79% involved the upper extremity, and 27% required reduction. Overall, 15% of children were prescribed an opioid at discharge, with variation between the four EDs: A = 8.2% (95% confidence interval [CI] = 6.9–9.7%), B = 12.1% (95% CI = 10.5–14.0%), C = 16.9% (95% CI = 15.2–18.8%), D = 23.8% (95% CI = 21.7–26.1%). Oxycodone was the most frequently prescribed opioid. In the regression analysis, in addition to variation by ED site of care, age 12–18 years, white non-Hispanic, private insurance status, reduced fracture, and severe pain documented during the ED visit were associated with increased opioid prescribing. Conclusions For children with a long-bone fracture, discharge opioid prescription varied widely by ED site of care. In addition, black patients, Hispanic patients, and patients with government insurance were less likely to be prescribed opioids. This variability in opioid prescribing was not accounted for by patient- or injury-related factors that are associated with increased pain. Therefore, opioid prescribing may be modifiable, but evidence to support improved outcomes with specific treatment regimens is lacking. [ABSTRACT FROM AUTHOR]

Differences in the quality of emergency department (ED) care are often attributed to nonclinical factors such as variations in the structure, systems, and processes of care. Few studies have examined these associations among children. We aimed to determine whether process measures of quality of care delivered to patients receiving care in children's hospital EDs were associated with physician-level or hospital-level factors. We included children (<18 years old) who presented to any of the 12 EDs participating in the Pediatric Emergency Care Applied Research Network (PECARN) between January 2011 and December 2011. We measured quality of care from medical record reviews using a previously validated implicit review instrument with a summary score ranging from 5 to 35, and examined associations between process measures of quality and physician- and hospital-level factors using a mixed-effects linear regression model adjusted for patient case-mix, with hospital site as a random effect. Among the 620 ED encounters reviewed, we did not find process measures of quality to be associated with any physician-level factors such as physician sex, years since medical school graduation, or physician training. We found, however, that process measures of quality were positively associated with delivery at freestanding children's hospitals (1.96 points higher in quality compared to nonfreestanding status, 95% confidence interval: 0.49, 3.43) and negatively associated with higher annual ED patient volume (−0.03 points per thousand patients, 95% confidence interval: −0.05, −0.01). Process measures of quality of care delivered to children were higher among patients treated at freestanding children's hospitals but lower among patients treated at higher volume EDs. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the impact of transcervical ultrasound (US) as the initial imaging study for suspected peritonsillar abscesses (PTAs) on pediatric emergency department (ED) throughput measures. Methods: A retrospective cohort study of patients evaluated for suspected PTAs between January 2009 and April 2017 was conducted. We compared the ED length of stay (LOS) before and after implementation of transcervical US to diagnose a PTA. The balancing measure was the rate of return visits within 2 weeks. Results: There were 387 eligible patients over the study period. A total of 101 patients were evaluated for PTAs with computed tomography and 286 with US. The mean LOS was significantly less for patients who had US (347 minutes; 95% confidence interval [CI], 330, 364 minutes) compared to computed tomography (426 minutes; 95% CI, 392, 459 minutes), with an absolute difference of 79 minutes (95% CI, 44, 113 minutes). Patients who were evaluated with US did not have an increased rate of return visits (5.9% versus 8.0%; P =.66). Conclusions: The introduction of transcervical US was associated with a decrease of greater than 1 hour in the ED LOS for patients with suspected PTAs. Given the better radiation profile of US and no increase in the rate of return visits after its implementation, we propose the adoption of a transcervical US‐first approach for the diagnosis of PTAs in pediatrics. [ABSTRACT FROM AUTHOR]

Objectives: Pediatric asthma is a leading cause of emergency department (ED) utilization and hospitalization. Earlier identification of need for hospital‐level care could triage patients more efficiently to high‐ or low‐resource ED tracks. Existing tools to predict disposition for pediatric asthma use only clinical data, perform best several hours into the ED stay, and are static or score‐based. Machine learning offers a population‐specific, dynamic option that allows real‐time integration of available nonclinical data at triage. Our objective was to compare the performance of four common machine learning approaches, incorporating clinical data available at the time of triage with information about weather, neighborhood characteristics, and community viral load for early prediction of the need for hospital‐level care in pediatric asthma. Methods: Retrospective analysis of patients ages 2 to 18 years seen at two urban pediatric EDs with asthma exacerbation over 4 years. Asthma exacerbation was defined as receiving both albuterol and systemic corticosteroids. We included patient features, measures of illness severity available in triage, weather features, and Centers for Disease Control and Prevention influenza patterns. We tested four models: decision trees, LASSO logistic regression, random forests, and gradient boosting machines. For each model, 80% of the data set was used for training and 20% was used to validate the models. The area under the receiver operating characteristic (AUC) curve was calculated for each model. Results: There were 29,392 patients included in the analyses: mean (±SD) age of 7.0 (±4.2) years, 42% female, 77% non‐Hispanic black, and 76% public insurance. The AUCs for each model were: decision tree 0.72 (95% confidence interval [CI] = 0.66–0.77), logistic regression 0.83 (95% CI = 0.82–0.83), random forests 0.82 (95% CI = 0.81–0.83), and gradient boosting machines 0.84 (95% CI = 0.83–0.85). In the lowest decile of risk, only 3% of patients required hospitalization; in the highest decile this rate was 100%. After patient vital signs and acuity, age and weight, followed by socioeconomic status (SES) and weather‐related features, were the most important for predicting hospitalization. Conclusions: Three of the four machine learning models performed well with decision trees preforming the worst. The gradient boosting machines model demonstrated a slight advantage over other approaches at predicting need for hospital‐level care at the time of triage in pediatric patients presenting with asthma exacerbation. The addition of weight, SES, and weather data improved the performance of this model. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the consistency, reliability, and validity of an implicit review instrument that measures the quality of care provided to children in the emergency department (ED).Data Sources/study Setting: Medical records of randomly selected children from 12 EDs in the Pediatric Emergency Care Applied Research Network (PECARN).Study Design: Eight pediatric emergency medicine physicians applied the instrument to 620 medical records.Data Collection/extraction Methods: We determined internal consistency using Cronbach's alpha and inter-rater reliability using the intraclass correlation coefficient (ICC). We evaluated the validity of the instrument by correlating scores with four condition-specific explicit review instruments.Principal Findings: Individual reviewers' Cronbach's alpha had a mean of 0.85 with a range of 0.76-0.97; overall Cronbach's alpha was 0.90. The ICC was 0.49 for the summary score with a range from 0.40 to 0.46. Correlations between the quality of care score and the four condition-specific explicit review scores ranged from 0.24 to 0.38.Conclusions: The quality of care instrument demonstrated good internal consistency, moderate inter-rater reliability, high inter-rater agreement, and evidence supporting validity. The instrument could be useful for systems' assessment and research in evaluating the care delivered to children in the ED. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Quality of care delivered to adult patients in the emergency department (ED) is often associated with demographic and clinical factors such as a patient's race/ethnicity and insurance status. We sought to determine whether the quality of care delivered to children in the ED was associated with a variety of patient‐level factors. Methods: This was a retrospective, observational cohort study. Pediatric patients (<18 years) who received care between January 2011 and December 2011 at one of 12 EDs participating in the Pediatric Emergency Care Applied Research Network (PECARN) were included. We analyzed demographic factors (including age, sex, and payment source) and clinical factors (including triage, chief complaint, and severity of illness). We measured quality of care using a previously validated implicit review instrument using chart review with a summary score that ranged from 5 to 35. We examined associations between demographic and clinical factors and quality of care using a hierarchical multivariable linear regression model with hospital site as a random effect. Results: In the multivariable model, among the 620 ED encounters reviewed, we did not find any association between patient age, sex, race/ethnicity, and payment source and the quality of care delivered. However, we did find that some chief complaint categories were significantly associated with lower than average quality of care, including fever (–0.65 points in quality, 95% confidence interval [CI] = –1.24 to –0.06) and upper respiratory symptoms (–0.68 points in quality, 95% CI = –1.30 to –0.07). Conclusion: We found that quality of ED care delivered to children among a cohort of 12 EDs participating in the PECARN was high and did not differ by patient age, sex, race/ethnicity, and payment source, but did vary by the presenting chief complaint. [ABSTRACT FROM AUTHOR]

Objective The objective was to develop a content-valid audio computer-assisted self-interview ( ACASI) sexual health survey ( SHS) that is understandable and acceptable to adolescents and can be feasibly implemented in a pediatric emergency department ( ED) for sexually transmitted infection ( STI) risk assessment. Methods Multistep iterative qualitative study utilizing a Delphi panel of key informants for survey development and content validity, cognitive interviews with end-users to evaluate understanding, and pilot testing with end-users to evaluate acceptability and feasibility. Results We developed a 20-item questionnaire through an iterative modified Delphi process with experts in adolescent and pediatric emergency medicine. All items were assessed as understandable by >90% of adolescents during the cognitive interviews. All respondents found the SHS easy to use. A total of 76.5% preferred answering questions related to sexual health through the SHS compared to face-to-face interviews. Mean (± SD) length of survey completion was 17.5 (±6.7) minutes and 88.6% of participants found survey length to be 'just right.' With respect to feasibility testing, there was no statistically significant difference in median ED LOS between those who piloted the SHS and those who did not (230.0 minutes vs. 219.0 minutes; p = 0.7). Conclusions We developed a content-valid ACASI for the identification of adolescents at risk for STIs that was understandable, acceptable, and easy to use by adolescent patients and feasible for implementation in the pediatric ED. Future planned steps include the evaluation of the SHS in providing clinical decision support for targeted STI screening in the ED. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Copyright of Academic Emergency Medicine is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Objectives Prescription errors occur frequently in pediatric emergency departments ( PEDs).The effect of computerized physician order entry ( CPOE) with electronic medication alert system ( EMAS) on these is unknown. The objective was to compare prescription errors rates before and after introduction of CPOE with EMAS in a PED. The hypothesis was that CPOE with EMAS would significantly reduce the rate and severity of prescription errors in the PED. Methods A prospective comparison of a sample of outpatient, medication prescriptions 5 months before and after CPOE with EMAS implementation (7,268 before and 7,292 after) was performed. Error types and rates, alert types and significance, and physician response were noted. Medication errors were deemed significant if there was a potential to cause life-threatening injury, failure of therapy, or an adverse drug effect. Results There was a significant reduction in the errors per 100 prescriptions (10.4 before vs. 7.3 after; absolute risk reduction = 3.1, 95% confidence interval [ CI] = 2.2 to 4.0). Drug dosing error rates decreased from 8 to 5.4 per 100 (absolute risk reduction = 2.6, 95% CI = 1.8 to 3.4). Alerts were generated for 29.6% of prescriptions, with 45% involving drug dose range checking. The sensitivity of CPOE with EMAS in identifying errors in prescriptions was 45.1% (95% CI = 40.8% to 49.6%), and the specificity was 57% (95% CI = 55.6% to 58.5%). Prescribers modified 20% of the dosing alerts, resulting in the error not reaching the patient. Conversely, 11% of true dosing alerts for medication errors were overridden by the prescribers: 88 (11.3%) resulted in medication errors, and 684 (88.6%) were false-positive alerts. Conclusions A CPOE with EMAS was associated with a decrease in overall prescription errors in our PED. Further system refinements are required to reduce the high false-positive alert rates. [ABSTRACT FROM AUTHOR]

Objectives The objectives were to estimate the frequency of pregnancy testing in emergency department ( ED) visits by reproductive-aged women administered or prescribed teratogenic medications (Food and Drug Administration categories D or X) and to determine factors associated with nonreceipt of a pregnancy test. Methods This was a retrospective cross-sectional study using 2005 through 2009 National Hospital Ambulatory Medical Care Survey data of ED visits by females ages 14 to 40 years. The number of visits was estimated where teratogenic medications were administered or prescribed and pregnancy testing was not conducted. The association of demographic and clinical factors with nonreceipt of pregnancy testing was assessed using multivariable logistic regression. Results Of 39,859 sampled visits, representing an estimated 141.0 million ED visits by reproductive-aged females nationwide, 10.1 million (95% confidence interval [ CI] = 8.9 to 11.3 million) estimated visits were associated with administration or prescription of teratogenic medications. Of these, 22.0% (95% CI = 19.8% to 24.2%) underwent pregnancy testing. The most frequent teratogenic medications administered without pregnancy testing were benzodiazepines (52.2%; 95% CI = 31.1% to 72.7%), antibiotics (10.7%; 95% CI = 5.0% to 16.3%), and antiepileptics (7.7%; 95% CI = 0.12% to 15.5%). The most common diagnoses associated with teratogenic drug prescription without pregnancy testing were psychiatric (16.1%; 95% CI = 13.6% to 18.6%), musculoskeletal (12.7%; 95% CI = 10.8% to 14.5%), and cardiac (9.5%; 95% CI = 7.6% to 11.3%). In multivariable analyses, visits by older (adjusted odds ratio [ AOR] = 0.57, 95% CI = 0.42 to 0.79), non-Hispanic white females ( AOR = 0.71; 95% CI = 0.54 to 0.93); visits in the Northeast region ( AOR = 0.60; 95% CI = 0.42 to 0.86); and visits during which teratogenic medications were administered in the ED only ( AOR = 0.74; 95% CI = 0.57 to 0.97) compared to prescribed at discharge only were less likely to have pregnancy testing. Conclusions A minority of ED visits by reproductive-aged women included pregnancy testing when patients were prescribed category D or X medications. Interventions are needed to ensure that pregnancy testing occurs before women are prescribed potentially teratogenic medications, as a preventable cause of infant morbidity. [ABSTRACT FROM AUTHOR]

Copyright of Academic Emergency Medicine is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

A formal emergency care system for children in the United States began in the 1980s with the establishment of specialized training programs in academic children's hospitals. The ensuing three decades have witnessed the establishment of informal regional networks for clinical care and a federally funded research consortium that allows for multisite research on evidence-based practices. However, pediatric emergency care suffers from problems common to emergency departments (EDs) in general, which include misaligned incentives for care, overcrowding, and wide variation in the quality of care. In pediatric emergency care specifically, there are problems with low-volume EDs that have neither the experience nor the equipment to treat children, poor adherence to clinical guidelines, lack of resources for mental health patients, and a lack of widely accepted performance metrics. We call for policies to address these issues, including providing after-hours care in other settings and restructuring payment and reimbursement policies to better address patients' needs. [ABSTRACT FROM AUTHOR]

ACADEMIC EMERGENCY MEDICINE 2012; 19:70-78 © 2012 by the Society for Academic Emergency Medicine Abstract Objectives: Lack of adequate risk adjustment methodologies has hindered the progress of emergency medicine health services research. The authors hypothesized that a consensus-derived, diagnosis-based severity classification system (SCS) would be significantly associated with actual measures of emergency department (ED) resource use and could ultimately be used to examine severity-adjusted outcomes across patient populations. Methods: A panel of subject matter experts used consensus methods to assign severity scores (1 = lowest severity to 5 = highest severity) to 3,041 ED International Classifications of Diseases (ICD), 9th revision, diagnosis codes. SCS scores were assigned to ED visits using the visit diagnosis code with the highest severity. We tested the association between the SCS scores and measures of ED resource use in three data sets: the Pediatric Emergency Care Applied Research Network Core Data Project (PCDP), the National Hospital Ambulatory Medical Care Survey (NHAMCS), and the Connecticut state ED data set. Results: There was a significant association between the five-level SCS and all six measures of resource use: triage category, disposition, ED resource use, Current Procedural Terminology Evaluation and Management (CPT E&M) codes, ED length of stay, and ED charges within the three ED data sets. Conclusions: The SCS demonstrates validity in its strong association with actual ED resource use. The use of readily available ICD-9 diagnosis codes makes the SCS useful as a risk adjustment tool for health services research. [ABSTRACT FROM AUTHOR]

The article discusses the results of a study which examined existing performance measures that are pertinent to pediatric emergency care. A description of a survey of peer-reviewed literature, emergency department (ED) directors and Web sites of societies and organizations related to quality improvement is provided. The study showed that out of the 405 performance measures, about 50 percent were related to effectiveness and six percent to patient-centeredness. It concludes that performance measures are not apt to evaluate the quality of care.

Objectives: A clinically sensible system of grouping diseases is needed for describing pediatric emergency diagnoses for research and reporting. This project aimed to create an International Classification of Diseases (ICD)-based diagnosis grouping system (DGS) for child emergency department (ED) visits that is 1) clinically sensible with regard to how diagnoses are grouped and 2) comprehensive in accounting for nearly all diagnoses (>95%). The second objective was to assess the construct validity of the DGS by examining variation in the frequency of targeted groups of diagnoses within the concepts of season, age, sex, and hospital type. Methods: A panel of general and pediatric emergency physicians used the nominal group technique and Delphi surveys to create the DGS. The primary data source used to develop the DGS was the Pediatric Emergency Care Applied Research Network (PECARN) Core Data Project (PCDP). Results: A total of 3,041 ICD-9 codes, accounting for 98.9% of all diagnoses in the PCDP, served as the basis for creation of the DGS. The expert panel developed a DGS framework representing a clinical approach to the diagnosis and treatment of pediatric emergency patients. The resulting DGS has 21 major groups and 77 subgroups and accounts for 96.5% to 99% of diagnoses when applied to three external data sets. Variations in the frequency of targeted groups of diagnoses related to seasonality, age, sex, and site of care confirm construct validity. Conclusions: The DGS offers a clinically sensible method for describing pediatric ED visits by grouping ICD-9 codes in a consensus-derived classification scheme. This system may be used for research, reporting, needs assessment, and resource planning. ACADEMIC EMERGENCY MEDICINE 2010; 17:204–213 © 2010 by the Society for Academic Emergency Medicine [ABSTRACT FROM AUTHOR]

Describes the etiology and outcome of emergency department (ED) diagnoses in pediatric population with bilious emesis. Signs and symptoms of bilious emesis; Determination of the proportion of bilious emesis patients requiring surgical interventions; Demonstration of ED diagnoses and disposition for patients stratified by age.

We performed a clinical trial of a new tympanic thermometer to test its accuracy in a pediatric emergency department. Tympanic temperature was compared to oral or rectal glass and electronic temperature, depending on the developmental age of the child. Results were controlled for age of the child, cooperation, quantity of cerumen, and the presence or absence of otitis media. Our results suggest good correlation of tympanic with oral and rectal glass thermometry except in infants less than three months of age. Sensitivity and specificity, respectively, were 80% and 93% for detecting fever of 38°C and 80% and 95% for detecting fever of 38.5°C. [ABSTRACT FROM AUTHOR]

In the article, the authors present a retrospective cross-sectional study which examined the racial/ethnic differences and trends in emergency department (ED) opioid prescriptions for long bone fractures. Also cited are how pain compelled physicians to prescribe opioid to pediatric patients in ED, and the race/ethnicity categories in the study like non-Hispanic White, Hispanic, and non-Hispanic Africans.

OBJECTIVES: To test the hypotheses that minority children with long-bone fractures are less likely to (1) receive analgesics, (2) receive opioid analgesics, and (3) achieve pain reduction. METHODS: We performed a 3-year retrospective cross-sectional study of children,18 years old with long-bone fractures using the Pediatric Emergency Care Applied Research Network Registry (7 emergency departments). We performed bivariable and multivariable logistic regression to measure the association between patient race and ethnicity and (1) any analgesic, (2) opioid analgesic, (3) ≤2-point pain score reduction, and (4) optimal pain reduction (ie, to mild or no pain). RESULTS: In 21 069 visits with moderate-to-severe pain, 86.1% received an analgesic and 45.4% received opioids. Of 8533 patients with reassessment of pain, 89.2% experienced $2-point reduction in pain score and 62.2% experienced optimal pain reduction. In multivariable analyses, minority children, compared with non-Hispanic (NH) white children, were more likely to receive any analgesics (NH African American: adjusted odds ratio [aOR] 1.72 [95% confidence interval 1.51-1.95]; Hispanic: 1.32 [1.16-1.51]) and achieve $2-point reduction in pain (NH African American: 1.42 [1.14-1.76]; Hispanic: 1.38 [1.04-1.83]) but were less likely to receive opioids (NH African American: aOR 0.86 [0.77-0.95]; Hispanic: aOR 0.86 [0.76-0.96]) or achieve optimal pain reduction (NH African American: aOR 0.78 [0.67-0.90]; Hispanic: aOR 0.80 [0.67-0.95]). CONCLUSIONS: There are differences in process and outcome measures by race and ethnicity in the emergency department management of pain among children with long-bone fractures. Although minority children are more likely to receive analgesics and achieve ≤2-point reduction in pain, they are less likely to receive opioids and achieve optimal pain reduction. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: In the primary care setting, there are racial and ethnic differences in antibiotic prescribing for acute respiratory tract infections (ARTIs). Viral ARTIs are commonly diagnosed in the pediatric emergency department (PED), in which racial and ethnic differences in antibiotic prescribing have not been previously reported. We sought to investigate whether patient race and ethnicity was associated with differences in antibiotic prescribing for viral ARTIs in the PED. METHODS: This is a retrospective cohort study of encounters at 7 PEDs in 2013, in which we used electronic health data from the Pediatric Emergency Care Applied Research Network Registry. Multivariable logistic regression was used to examine the association between patient race and ethnicity and antibiotics administered or prescribed among children discharged from the hospital with viral ARTI. Children with bacterial codiagnoses, chronic disease, or who were immunocompromised were excluded. Covariates included age, sex, insurance, triage level, provider type, emergency department type, and emergency department site. RESULTS: Of 39 445 PED encounters for viral ARTIs that met inclusion criteria, 2.6% (95% confidence interval [Cl] 2.4%-2.8%) received antibiotics, including 4.3% of non-Hispanic (NH) white, 1.9% of NH black, 2.6% of Hispanic, and 2.9% of other NH children. In multivariable analyses, NH black (adjusted odds ratio [aOR] 0.44; Cl 0.36-0.53), Hispanic (aOR 0.65; Cl 0.53-0.81), and other NH (aOR 0.68; Cl 0.52-0.87) children remained less likely to receive antibiotics for viral ARTIs. CONCLUSIONS: Compared with NH white children, NH black and Hispanic children were less likely to receive antibiotics for viral ARTIs in the PED. Future research should seek to understand why racial and ethnic differences in overprescribing exist, including parental expectations, provider perceptions of parental expectations, and implicit provider bias. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To describe national emergency department (ED) trends in computed tomography (CT) and ultrasound imaging for the evaluation of pediatric nontraumatic abdominal pain from 2007 through 2014. METHODS: We used data from the National Hospital Ambulatory Medical Care Survey to measure trends in CT and ultrasound use among children with nontraumatic abdominal pain. We performed multivariable logistic regression to measure the strength ofthe association of ED type (pediatric versus general ED) with CT and ultrasound use adjusting for potential confounding variables. RESULTS: Of an estimated 21.1 million ED visits for nontraumatic abdominal pain, 14.6% (95% confidence interval [Cl], 13.2%-16.0%) had CT imaging only, 10.9% (95% Cl, 9.7%- 12.1%) had ultrasound imaging only, and 1.9% (95% Cl, 1.4%-2.4%) received both CT and ultrasound. The overall use of CT and ultrasound did not significantly change over the study period (P trend .63 and .90, respectively). CT use was lower among children treated in pediatric EDs compared with general EDs (adjusted odds ratio 0.34; 95% Cl, 0.17-0.69). Conversely, ultrasound use was higher among children treated in pediatric EDs compared with general EDs (adjusted odds ratio 2.14; 95% Cl, 1.29-3.55). CONCLUSIONS: CT imaging for pediatric patients with nontraumatic abdominal pain has plateaued since 2007 after the steady increase seen in the preceding 9 years. Among this population, an increased likelihood of CT imaging was demonstrated in general EDs compared with pediatric EDs, in which there was a higher likelihood of ultrasound imaging. Dissemination of pediatric-focused radiology protocols to general EDs may help optimize radiation exposure in children. [ABSTRACT FROM AUTHOR]

BACKGROUND: Asthma triggers >775 000 emergency department (ED) visits for children each year. Approximately 80% of these visits occur in community EDs. We performed this study to measure effects of partnership with a community ED on pediatric asthma care. METHODS: For this quality improvement initiative, we implemented an evidence-based pediatric asthma guideline in a community ED. We included patients whose clinical impression in the medical decision section of the electronic health record contained the words asthma, bronchospasm, or wheezing. We reviewed charts of included patients 12 months before guideline implementation (August 2012-July 2013) and 19 months after guideline implementation (August 2013-February 2015). Process measures included the proportion of children who had an asthma score recorded, the proportion who received steroids, and time to steroid administration. The outcome measure was the proportion of children who needed transfer for additional care. RESULTS: In total, 724 patients were included, 289 during the baseline period and 435 after guideline implementation. Overall, 64% of patients were assigned an asthma score after guideline implementation. During the baseline period, 60% of patients received steroids during their ED visit, compared with 76% after guideline implementation (odds ratio 2.2; 95% confidence interval, 1.6-3.0). After guideline implementation, the mean time to steroids decreased significantly, from 196 to 105 minutes [P < .001). Significantly fewer patients needed transfer after guideline implementation (10% compared with 14% during the baseline period) (odds ratio 0.63; 95% confidence interval, 0.40-0.99). CONCLUSIONS: Our study shows that partnership between a pediatric tertiary care center and a community ED is feasible and can improve pediatric asthma care. [ABSTRACT FROM AUTHOR]