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.
A 4-day-old breastfed infant presented with opioid intoxication resulting from the maternal use of oxycodone after cesarean delivery. The infant was hypothermic, lethargic, and had pinpoint pupils. A ...dose of naloxone reversed the symptoms. This report highlights the importance of recognizing the potential effects of maternal oxycodone on the breastfed neonate in the emergency department setting.
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.
Two of the most prevalent problems facing youth in the United States are injury and obesity. Obesity increases the risk of injury, prolongs recovery time, and increases morbidity among injured ...children.
The purpose of this study was to compare characteristics of injuries between obese and nonobese children who presented to a pediatric emergency department.
Electronic medical records for all patients aged 3 to 14 years who sustained a traumatic injury (International Classification of Diseases, Ninth Revision ICD-9 codes 800-899) and were seen in our hospital emergency department from January 1, 2005, to March 31, 2008, were obtained. Data collected included age, chief complaint, discharge diagnosis, gender, race, disposition, and weight. Patients with a weight at >95th percentile for age were considered obese. chi(2) analysis was used in comparing the groups; odds ratios (ORs) were calculated.
During the study period, 24 588 children had ICD-9 codes that met our inclusion criteria. Of these, 1239 had no weights recorded, leaving 23 349 patients in our study population. Of these children, the mean age was 8.2 years (SD: +/-3.6 years), 60.7% were white, and 61.7% were male. Obese children represented 16.5% of the study population (n = 3861). Overall, obese and nonobese children had the same percentage of upper extremity injuries. However, obese children were significantly more likely to have lower extremity injuries compared with upper extremity injuries than were nonobese children (OR: 1.71 95% confidence interval: 1.56-1.87; P < .001). In addition, obese children had significantly fewer head and face injuries than nonobese children (OR: 0.54 95% confidence interval: 0.50- 0.58; P < .001).
Obese children are significantly more likely to sustain lower extremity injuries than upper extremity injuries and less likely to sustain head and face injuries than nonobese children. Strategies for preventing lower extremity injuries among obese youth should be sought.
Migraine headache is a common presenting condition to the pediatric emergency department (PED). Dopamine receptor antagonists, such as prochlorperazine and metoclopramide, serve as the primary ...treatment for migraine headache in many emergency departments; however, in 2012, our institution experienced a shortage of these drugs, resulting in the use of alternative medications. Chlorpromazine was included as an option for treatment at our institution during this shortage, although limited data exist on the effectiveness in children.
The objectives of this study were: (1) to compare the treatment failure rate of chlorpromazine in the treatment of migraine headache in youth presenting to the PED with those who received prochlorperazine; and (2) to identify the frequency and type of adverse events, and change in pain score.
We performed a retrospective cohort study of patients 12-21 years of age treated for migraine headache in our emergency department. Our treatment group received intravenous chlorpromazine between February and April 2012, while the comparison group consisted of children treated with intravenous prochlorperazine between February and April 2011. The outcomes of interest were: (1) treatment failure, defined as need for additional therapy, hospitalization or 48-hour return; (2) adverse reactions to drug therapy; and (3) change in pain score.
This study yielded 75 patients in the treatment group and 274 in the comparison group. Forty percent (30/75) of the treatment group had treatment failure compared with 15% (41/274) of the comparison group. There was no difference in mean change in pain score between the groups. The most common adverse effects included hypotension in the treatment group (12%) and akathisia in the comparison group (12%).
This is the first study that has examined the use of chlorpromazine as a therapy in pediatric migraines. Abortive therapy for migraine headache in the PED with chlorpromazine is associated with greater need for rescue medication and hospitalization, and higher rates of hypotension.
Background: Understanding the impact of overcrowding in pediatric emergency departments (PEDs) on quality of care is a growing concern. Boarding admitted patients in the PED and increasing emergency ...department (ED) visits are two potentially significant factors affecting quality of care.
Objectives: The objective was to describe the impact ED boarding time and daily census have on the timeliness of care in a PED.
Methods: Pediatric ED boarding time and daily census were determined each day from July 2003 to July 2007. Outcome measures included mean length of stay (LOS), time to triage, time to physician, and patient elopement during a 24‐hour period.
Results: For every 50 patients seen above the average daily volume of 250, LOS increased 14.8 minutes, time to triage increased 6.6 minutes, time to physician increased 18.2 minutes, and number of patient elopements increased by three. For each increment of 24 hours to total ED boarding time, LOS increased 7.6 minutes, time to triage increased 0.6 minutes, time to physician increased 3 minutes, and number of patient elopements increased by 0.6 patients.
Conclusions: ED boarding time and ED daily census show independent associations with increasing overall LOS, time to triage, time to physician, and number of patient elopements in a PED.
Study objective We develop a comprehensive view of aspects of care associated with parental satisfaction with pediatric emergency department (ED) visits, using both quantitative and qualitative data. ...Methods This was a retrospective observational study using data from an institution-wide system to measure patient satisfaction. For this study, 2,442 parents who brought their child to the ED were interviewed with telephone survey methods. The survey included closed-ended (quantitative) and open-ended (qualitative data) questions, in addition to a cognitive interview–style question. Results Overall parental satisfaction was best predicted by how well physicians and nurses work together, followed by wait time and pain management. Issues concerning timeliness of care, perceived quality of medical care, and communication were raised repeatedly by parents in response to open-ended questions. A cognitive interview–style question showed that physicians and nurses sharing information with each other, parents receiving consistent and detailed explanations of their child's diagnosis and treatments, and not having to answer the same question repeatedly informed parent perceptions of physicians and nurses working well together. Staff showing courtesy and respect through compassion and caring words and behaviors and paying attention to nonmedical needs are other potential satisfiers with emergency care. Conclusion Using qualitative data to augment and clarify quantitative data from patient experience of care surveys is essential to obtaining a complete picture of aspects of emergency care important to parents and can help inform quality improvement work aimed at improving satisfaction with care.
Abstract Background More than 3.8 million children sustain traumatic brain injuries annually. Treatment of posttraumatic headache (PTH) in the emergency department (ED) is variable, and benefits are ...unclear. Objective The objective of the study is to determine if intravenous migraine therapy reduces pain scores in children with PTH and factors associated with improved response. Methods This was a retrospective study of children, 8 to 21 years old, presenting to a tertiary pediatric ED with mild traumatic brain injury (mTBI) and PTH from November 2009 to June 2013. Inclusion criteria were mTBI (defined by diagnosis codes) within 14 days of ED visit, headache, and administration of one or more intravenous medications: ketorolac, prochlorperazine, metoclopramide, chlorpromazine, and ondansetron. Primary outcome was treatment success defined by greater than or equal to 50% pain score reduction during ED visit. Bivariate analysis and logistic regression were used to determine predictors of treatment success: age, sex, migraine or mTBI history, time since injury, ED head computed tomographic (CT) imaging, and pretreatment with oral analgesics. Results A total of 254 patients were included. Mean age was 13.8 years, 51% were female, 80% were white, mean time since injury was 2 days, and 114 patients had negative head CTs. Eighty-six percent of patients had treatment success with 52% experiencing complete resolution of headache. Bivariate analysis showed that patients who had a head CT were less likely to respond (80% vs 91%; P = .008). Conclusions Intravenous migraine therapy reduces PTH pain scores for children presenting within 14 days after mTBI. Further prospective work is needed to determine long-term benefits of acute PTH treatment in the ED.
Objectives
The objective was to determine whether several measures of emergency department (ED) crowding are associated with an important indicator of quality and safety: time to reevaluation of ...children with documented critically abnormal triage vital signs.
Methods
This was a retrospective cross‐sectional study of all patients with critically abnormal vital signs measured in triage over a 2.5‐year period (September 1, 2006, to May 1, 2009). Cox proportional hazard analysis was used to determine rate ratios for time to critically abnormal vital sign reassessment, when controlled for potential confounders.
Results
In this 2.5‐year sample, 9,976 patients with critically abnormal vital signs in triage (representing 3.9% of 253,408 visits) were placed in regular ED rooms with electronic alerts prompting vital sign reassessment after 1 hour. Overall, the mean time to reassessment was 84 minutes. The rate of vital sign reassessment was reduced by 31% for each additional 10 patients waiting for admission (adjusted odds ratio OR = 0.98; 95% confidence interval CI = 0.98 to 0.99), by 10% for every 10 patients in the lobby (adjusted OR = 0.94; 95% CI = 0.93 to 0.96), and by 6% for every additional 10 patients in the overall ED census (adjusted OR = 0.97; 95% CI = 0.97 to 0.98).
Conclusions
Emergency department crowding was associated with delay in the reassessment of critically abnormal vital signs in children; further work is needed to develop systems to mitigate these delays.
Resumen
Objetivos
Determinar si diversas medidas de la saturación del servicio de urgencias (SU) se asocian con un indicador importante de calidad y seguridad: el tiempo para la revaloración de niños con inestabilidad hemodinámica documentada en el triaje.
Metodología
Estudio retrospectivo de análisis transversal de todos los pacientes con inestabilidad hemodinámica identificada en el triaje durante un periodo de 2,5 años (1 de septiembre de 2006 hasta 1 de mayo de 2009). Se utilizó un análisis de riesgos proporcionales de Cox para determinar la razón de tasas para el tiempo hasta la revaloración de la inestabilidad hemodinámica una vez controlado el modelo por los potenciales factores de confusión.
Resultados
En esta muestra de 2,5 años, 9.976 pacientes con inestabilidad hemodinámica en el triaje (representaron un 3,9% de las 253.408 visitas) fueron situados en habitaciones comunes del SU con una alerta electrónica que origina una revaloración de las constantes vitales tras una hora. Del total, la media de tiempo hasta la revaloración fue de 84 minutos. La frecuencia de revaloración de las constantes vitales se redujo un 31% por cada 10 pacientes adicionales esperando para el ingreso (odds ratio ajustada OR 0,98; IC 95% = 0,98 a 0,99); un 10% por cada 10 pacientes en la recepción (OR ajustada 0,94; IC 95% = 0,93 a 0,96); y un 6% por cada 10 pacientes adicionales en el censo global de SU (OR ajustada 0,97; IC 95% = 0,97 a 0,98).
Conclusiones
La saturación del servicio de urgencias se asoció con un retraso en la revaloración de la inestabilidad hemodinámica en los niños; será preciso trabajar en el futuro para desarrollar sistemas que mitiguen estos retrasos.
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