Objective To assess the impact of chronic conditions on children's emergency department (ED) use. Study design Retrospective analysis of 1 850 027 ED visits in 2010 by 3 250 383 children ages 1-21 ...years continuously enrolled in Medicaid from 10 states included in the Truven Marketscan Medicaid Database. The main outcome was the annual ED visit rate not resulting in hospitalization per 1000 enrollees. We compared rates by enrollees' characteristics, including type and number of chronic conditions, and medical technology (eg, gastrostomy, tracheostomy), using Poisson regression. To assess chronic conditions, we used the Agency for Healthcare Research and Quality's Chronic Condition Indicator system, assigning chronic conditions with ED visit rates ≥75th percentile as having the “highest” visit rates. Results The overall annual ED visit rate was 569 per 1000 enrollees. As the number of the children's chronic conditions increased from 0 to ≥3, visit rates increased by 180% (from 376 to 1053 per 1000 enrollees, P < .001). Rates were 174% higher in children assisted with vs without medical technology (1546 vs 565, P < .001). Sickle cell anemia, epilepsy, and asthma were among the chronic conditions associated with the highest ED visit rates (all ≥1003 per 1000 enrollees). Conclusions The highest ED visit rates resulting in discharge to home occurred in children with multiple chronic conditions, technology assistance, and specific conditions such as sickle cell anemia. Future studies should assess the preventability of ED visits in these populations and identify opportunities for reducing their ED use.
Objective The use of abdominal radiographs contributes to increased healthcare costs, radiation exposure, and potentially to misdiagnoses. We evaluated the association between abdominal radiograph ...performance and emergency department (ED) revisits with important alternate diagnosis among children with constipation. Study design Retrospective cohort study of children aged <18 years diagnosed with constipation at one of 23 EDs from 2004 to 2015. The primary exposure was abdominal radiograph performance. The primary outcome was a 3-day ED revisit with a clinically important alternate diagnosis. RAND/University of California, Los Angeles methodology was used to define whether the revisit was related to the index visit and due to a clinically important condition other than constipation. Regression analysis was performed to identify exposures independently related to the primary outcome. Results A total of 65.7% (185 439/282 225) of children with constipation had an index ED visit abdominal radiograph performed. Three-day revisits occurred in 3.7% (10 566/282 225) of children, and 0.28% (784/282 225) returned with a clinically important alternate related diagnosis. Appendicitis was the most common such revisit, accounting for 34.1% of all 3-day clinically important related revisits. Children who had an abdominal radiograph performed were more likely to have a 3-day revisit with a clinically important alternate related diagnosis (0.33% vs 0.17%; difference 0.17%; 95% CI 0.13-0.20). Following adjustment for covariates, abdominal radiograph performance was associated with a 3-day revisit with a clinically important alternate diagnosis (aOR: 1.39; 95% CI 1.15-1.67). Additional characteristics associated with the primary outcome included narcotic (aOR: 2.63) and antiemetic (aOR: 2.35) administration and underlying comorbidities (aOR: 2.52). Conclusions Among children diagnosed with constipation, abdominal radiograph performance is associated with an increased risk of a revisit with a clinically important alternate related diagnosis.
Objectives To quantify the number of shunt-related imaging studies that patients with ventricular shunts undergo and to calculate the proportion of computed tomography (CT) scans associated with a ...surgical intervention. Study design Retrospective longitudinal cohort analysis of patients up to age 22 years with a shunt placed January 2002 through December 2003 at a pediatric hospital. Primary outcome was the number of head CT scans, shunt series radiograph, skull radiographs, nuclear medicine, and brain magnetic resonance imaging studies for 10 years following shunt placement. Secondary outcome was surgical interventions performed within 7 days of a head CT. Descriptive statistics were used for analysis. Results Patients (n = 130) followed over 10 years comprised the study cohort. The most common reasons for shunt placement were congenital hydrocephalus (30%), obstructive hydrocephalus (19%), and atraumatic hemorrhage (18%), and 97% of shunts were ventriculoperitoneal. Patients underwent a median of 8.5 head CTs, 3.0 shunt series radiographs, 1.0 skull radiographs, 0 nuclear medicine studies, and 1.0 brain magnetic resonance imaging scans over the 10 years following shunt placement. The frequency of head CT scans was greatest in the first year after shunt placement (median 2.0 CTs). Of 1411 head CTs in the cohort, 237 resulted in surgical intervention within 7 days (17%, 95% CI 15%-19%). Conclusions Children with ventricular shunts have been exposed to large numbers of imaging studies that deliver radiation and most do not result in a surgical procedure. This suggests a need to improve the process of evaluating for ventricular shunt malfunction and minimize radiation exposure.
Abstract Objective The incidence of skin and soft tissue infections requiring incision and drainage has increased. Little evidence exists about the use of procedural sedation (PS) for these ...procedures in children. Our objective was to determine factors associated with the use of PS during incision and drainage procedures at a tertiary children's hospital. Methods This was a nested cohort study that combined a retrospective medical record review with prospectively collected data for children 2 months to 18 years old who had an incision and drainage procedure performed at a children's hospital over a 1-year period. Procedural sedation was defined as the use of pharmacologic agents to alter patient consciousness. Patient, lesion (eg, size and induration), provider (eg, years of experience), and emergency department (eg, patient volume and wait time) factors were analyzed. Emergency department physicians were divided into tertiles by frequency of sedation (high/medium/low) to assess provider practice variation. χ2 Analysis and multivariable logistic regression were used to identify factors associated with PS use. Results Of the 215 enrolled patients, 95 (44.2%) received PS. Ninety (94.7%) of 95 sedated patients received ketamine as their primary sedation agent. On univariate analysis, emergency department volume, wait time, duration of illness, and provider experience were not associated with PS use. With multivariable regression, patient age, abscess size, and provider frequency of sedation were all independently associated with the decision to sedate. Conclusions Patient age and abscess size are independent predictors of the use of PS for incision and drainage procedures. Provider practice patterns are also independently associated with PS use.
Objective To assess variation in the use of computed tomography (CT) for pediatric injury-related emergency department (ED) visits. Study design This was a retrospective cohort study of visits to 14 ...network-affiliated EDs from November 2010 through February 2013. Visits were identified by International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Primary outcome was CT use. We used descriptive statistics and performed multivariable logistic regression to evaluate the association of patient and ED covariates on any and body region–specific CT use. Results Of the 80 868 injury-related visits, 11.4% included CT, and 28.4% of those involved more than 1 CT. Across EDs, CT use ranged from 7.6% to 25.5% of visits and did not correlate with institutional Injury Severity Score ( P = .33) or admission/transfer rates ( P = .07). In multivariable analysis of nonpediatric EDs, trauma centers and nonacademic EDs were associated with CT use. Higher pediatric volume was associated with any CT use; however, there was an inverse relationship between volume and nonhead CT use. When the pediatric ED was included in multivariable modeling, the effect of level 1-3 trauma center designation remained, and the pediatric level 1 trauma center was less likely to use most body region–specific CTs. Conclusion There is wide variation in CT imaging for pediatric injury-related visits not attributable solely to case mix. Future work to optimize CT utilization should focus on additional factors contributing to imaging practices and interventions.
Abdominal pain in children Marin, Jennifer R; Alpern, Elizabeth R
Emergency medicine clinics of North America,
05/2011, Letnik:
29, Številka:
2
Journal Article
Recenzirano
Abdominal pain is one of the most common reasons pediatric patients seek emergency care. The emergency physician must be able to distinguish diagnoses requiring immediate attention from self-limiting ...processes. Pediatric patients can be challenging, particularly those who are preverbal, and therefore, the clinician must rely on a detailed history from a parent or caregiver as well as a careful physical examination in order to narrow the differential diagnosis. This article highlights several pediatric diagnoses presenting as abdominal pain, including surgical emergencies, nonsurgical diagnoses, and extraabdominal processes, and reviews the clinical presentation, diagnostic evaluation, and management of each.
...this study was within a single health system, and, therefore, the data may not generalize across all settings. Characteristic n (%) Sex, male 400 (52.8) Age (y), median (range) 43 (18-101) ...Race/ethnicity  Black, non-Hispanic 425 (56.1) White, non-Hispanic 245 (32.3) Other 65 (8.6) Missing 23 (3.0) Primary insurance  Private 211 (30.9) Medicare 178 (26.1) Medicaid 145 (21.3) Self-pay 148 (21.7) Missing 76 (10.0) Triage level (ESI)a  1 1 (0.13) 2 117 (15.4) 3 462 (60.1) 4 172 (22.7) 5 6 (0.79) Discharged  Clinical signs/symptomsb 634 (83.6) Loss of consciousness 177 (23.4) Amnesia 72 (9.5) Headache 418 (55.2) Emesis 18 (2.4) Age >60 years 206 (27.2) Drug or alcohol intoxication 109 (14.4) Short-term memory deficits 17 (2.2) Trauma above the clavicle 536 (70.7) Posttraumatic seizure 4 (0.5) GCS, <15 30 (4) Focal neurologic deficit 17 (2.2) Coagulopathy 52 (6.9) Severe headachec 8 (1) Age >=65 years 179 (23.6) Signs of basilar skull fracture 0 (0) Dangerous mechanism of injuryd 42 (5.5) Table Characteristics of visits for mild TBI (n = 758)
Abstract Background Pediatric abdominal pain visits to emergency departments (ED) are common. The objectives of this study are to assess variation in imaging ultrasound (US) ± computed tomography ...(CT) and factors associated with isolated CT use. Methods This was a retrospective cohort study of ED visits for pediatric abdominal pain resulting in discharge from 16 regional EDs from 2007–2013. Primary outcome was US or CT imaging. Secondary outcome was isolated CT use. We used multivariable logistic regression to evaluate patient- and hospital-level covariates associated with imaging. Results Of the 21 152 visits, imaging was performed in 29.7%, and isolated CT in 13.4% of visits. In multivariable analysis, black patients (OR: 0.4 (95%CI: 0.4, 0.5)) and Medicaid (OR: 0.6 (95%CI: 0.5, 0.7)) had lower odds of advanced imaging compared to white patients and private insurance, respectively. General EDs were less likely to perform imaging (OR: 0.6 (95%CI: 0.5, 0.7)) compared to the pediatric ED; however, for visits with imaging, 3.5% of visits to the pediatric ED compared to 76% of those to general EDs included an isolated CT (P < .001). Low pediatric volume (OR: 1.8 (95%CI:1.5, 2.2)) and rural (OR:1.8 (95%CI:1.3, 2.5)) EDs had higher odds of isolated CT use, compared to higher pediatric volumes and non-rural EDs, respectively. Conclusion There are racial and insurance disparities in imaging for pediatric abdominal pain. General EDs are less likely than pediatric EDs to use imaging, but more likely to use isolated CT. Strategies are needed to minimize disparities and improve the use of “ultrasound-first.”
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