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Emergency department (ED) crowding results when available resources cannot meet the demand for emergency services. ED crowding has negative impacts on patients, health care workers, and the community. Primary considerations for reducing ED crowding include improving the quality of care, patient safety, patient experience, and the health of populations, as well as reducing the per capita cost of health care. Evaluating causes, effects, and seeking solutions to ED crowding can be done within a conceptual framework addressing input, throughput, and output factors. ED leaders must coordinate with hospital leadership, health system planners and policy decision makers, and those who provide pediatric care to address ED crowding. Proposed solutions in this policy statement promote the medical home and timely access to emergency care for children., Competing Interests: FINANCIAL/POTENTIAL CONFLICT OF INTEREST DISCLOSURE: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2023 by the American Academy of Pediatrics.)

Emergency department (ED) crowding has been and continues to be a national concern. ED crowding is defined as a situation in which the identified need for emergency services outstrips available resources in the ED. Crowding is associated with higher morbidity and mortality, delayed pain control, delayed time to administration of antibiotics, increased medical errors, and less-than-optimal health care. ED crowding impedes a hospital's ability to achieve national quality and patient safety goals, diminishes the effectiveness of the health care safety net, and limits the capacity of hospitals to respond to a disaster and/or sudden surge in disease. Both children and adults seeking care in emergency settings are placed at risk. Crowding negatively influences the experience for patients, families, and providers, and can impact employee turnover and well-being. No single factor is implicated in creating the issue of crowding, but elements that influence crowding can be divided into those that affect input (prehospital and outpatient care), throughput (ED), and output (hospital and outpatient care). The degree of ED crowding is difficult to quantify but has been linked to markers such as hours on ambulance diversion, hours of inpatient boarding in the emergency setting, increasing wait times, and patients who leave without being seen. A number of organizations, including the American College of Emergency Physicians, the Emergency Nurses Association, and the National Quality Forum, have convened to better define emergency metrics and definitions that help provide data for benchmarks for patient throughput performance. The Joint Commission has acknowledged that patient safety is tied to patient throughput and has developed guidance for hospitals to ensure that hospital leadership engages in the process of safe egress of the patient out of the ED and, most recently, to address efficient disposition of patients with mental health emergencies. It is important that the American Academy of Pediatrics acknowledges the potential impact on access to optimal emergency care for children in the face of ED crowding and helps guide health policy decision-makers toward effective solutions that promote the medical home and timely access to emergency care., Competing Interests: FINANCIAL/POTENTIAL CONFLICT OF INTEREST DISCLOSURE: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2023 by the American Academy of Pediatrics.)

OBJECTIVES The goals of this study were to describe the factors associated with utilization of emergency services for nonurgent illnesses by insured children in a pediatric emergency department (PED) and to assess parental knowledge of their insurance and its influence on care-seeking behaviors. METHODS We conducted a prospective, descriptive survey of parents of insured children evaluated for nonurgent illnesses in an urban PED. RESULTS A total of 251 surveys were completed. The primary reason chosen by the parent for the PED visit was convenience in 62.8% of cases, a perceived true emergency in 33.6%, and lack of other access to a physician in 3.6%. Parents choosing the PED for perceived emergencies were more likely to state that the illness was life threatening or required hospital admission than those who came because of convenience (33/84 vs. 28/157; < 0.001). Only 38.7% stated that they were educated as to what problems are considered emergencies by their insurance carriers. PED referrals for nonurgent complaints are required by the insurance carrier for 74.9% of the population; however, only 37.2% of the parents stated that referrals were necessary. Primary care physician (PCP) contact was made prior to the visit by 45.4% of parents. Of those who called the PCP, 72.6% stated that they were referred to the PED. Of the parents who believed that a referral was required, those stating that the problem was an emergency were more likely to have contacted the PCP than those who came because of convenience (27/37 vs. 22/46; < P 0.037).CONCLUSIONS Parents frequently do not understand their insurance coverage as it relates to emergency care utilization. This lack of knowledge influences their care-seeking behaviors for nonurgent illnesses. Convenience is a significant factor in PED utilization for nonurgent complaints.

Purpose: To develop an improved model for the prediction of bacteremia in young febrile children., Methods: A retrospective review was performed on patients 3 to 36 months of age seen in a children's hospital emergency department between December 1995 and September 1997 who had a complete blood count and blood culture ordered as part of their regular care. Exclusion criteria included current use of antibiotics or any immunodeficient state. Clinical and laboratory parameters reviewed included age, gender, race, weight, temperature, presence of focal bacterial infection, white blood cell count (WBC), polymorphonuclear cell count (PMN), band count, and absolute neutrophil count (ANC). Logistic regression analyses were used to identify factors associated with bacteremia, defined as growth of a pathogen in a blood culture. The model that was developed was then validated on a second dataset consisting of febrile patients 3 to 36 months of age collected from a second children's hospital (validation set)., Results: There were 633 patients in the derivation set (46 bacteremic) and 9465 patients in the validation set (149 bacteremic). The mean age of patients in the derivation and validation sets were 15.8 months (95% confidence interval [CI]: 15.2-16.5) and 16.6 months (95% CI: 16.5-16.8), respectively; the mean temperatures were 39.1 degrees C (95% CI: 39. 0-39.2) and 39.8 degrees C (95% CI: 39.7-39.8); 56% were male in the derivation set and 55% male in the validation set. Predictors of bacteremia identified by logistic regression included ANC, WBC, PMN, temperature, and gender. Receiver operator characteristic (ROC) analysis showed similar performance of ANC and WBC as predictors of bacteremia. When placed into a multivariate logistic regression model, band count was not significantly associated with bacteremia. Information regarding focal infection was available for 572 patients in the derivation set. The percentage of patients diagnosed with bacteremia with a focal bacterial infection was not significantly different from the percentage who had bacteremia without a focal bacterial infection (16/200 vs 30/372). Based on this dataset, a logistic regression formula was developed that could be used to develop a unique risk value for each patient based on temperature, gender, and ANC. When the final model was applied to the validation set, the area under the ROC curve (AUC) constructed from these data indicated that the model retained good predictive value (AUC for the derivation vs validation data =.8348 vs 0.8221, respectively)., Conclusions: Use of the formulas derived here allows the clinician to estimate a child's risk for bacteremia based on temperature, ANC, and gender. This approach offers a useful alternative to predictions based on fever and WBC alone.bacteremia, detection, white blood cell.