While hospital admissions for myocardial infarction (MI) and pulmonary embolism (PE) are decreased during the COVID-19 pandemic, controversy remains about respective complication and mortality rates. ...This study evaluated admission rates, complications, and intrahospital mortality for selected life-threatening cardiovascular emergencies (MI, PE, and acute aortic dissection (AAD)) during COVID-19-associated restrictive social measures (RM) in Styria, Austria. By screening a patient information system for International Statistical Classification of Diseases and Related Health Problems (ICD) diagnosis codes covering more than 85% of acute hospital admissions in the state of Styria (~1.24 million inhabitants), we retrospectively identified patients with admission diagnoses for MI (I21, I22), PE (I26), and AAD (I71). Rates of complications such as cardiogenic shock and cardiopulmonary resuscitation, treatment escalations (thrombolysis for PE), and mortality were analyzed by patient chart review during 6 weeks following onset of COVID-19 associated RM, and during respective time frames in the years 2016 to 2019. 1,668 patients were included. Cumulative admissions for MI, PE and AAD decreased (RR 0.77; p<0.001) during RM compared to previous years. In contrast, intrahospital mortality increased by 65% (RR 1.65; p = 0.041), mainly driven by mortality following MI (RR 1.80; p = 0.042). PE patients received more frequently thrombolysis treatment (RR 3.63; p = 0.006), while rates of cardiogenic shock and cardiopulmonary resuscitation remained unchanged. Of 226 patients hospitalized during RM, 81 patients with suspected COVID-19 disease were screened for SARS-CoV-2 infection with only 5 testing positive. Thus, cumulative hospital admissions for cardiovascular emergencies decreased during COVID-19 associated RM while intrahospital mortality increased.
Children seeking care in the emergency department (ED) for mental health conditions are at risk for prolonged length of stay (LOS). A more contemporary description of trends and visit characteristics ...associated with prolonged ED LOS at the national level is lacking in the literature. Our objectives were to (1) compare LOS trends for pediatric mental health versus non-mental health ED visits and (2) explore patient-level characteristics associated with prolonged LOS for mental health ED visits.
We conducted an observational analysis of ED visits among children 6 to 17 years of age using the National Hospital Ambulatory Medical Care Survey (2005-2015). We assessed trends in rates of prolonged LOS and the association between prolonged LOS and demographic and clinical characteristics (race and ethnicity, payer type, and presence of a concurrent physical health diagnosis) using descriptive statistics and survey-weighted logistic regression.
From 2005 to 2015, rates of prolonged LOS for pediatric mental health ED visits increased over time from 16.3% to 24.6% (LOS >6 hours) and 5.3% to 12.7% (LOS >12 hours), in contrast to non-mental health visits for which LOS remained stable. For mental health visits, Hispanic ethnicity was associated with an almost threefold odds of LOS >12 hours (odds ratio 2.74; 95% confidence interval 1.69-4.44); there was no difference in LOS by payer type.
The substantial rise in prolonged LOS for mental health ED visits and disparity for Hispanic children suggest worsening and inequitable access to definitive pediatric mental health care. Policy makers and health systems should work to provide equitable and timely access to pediatric mental health care.
Parents often manage complex instructions when their children are discharged from the inpatient setting or emergency department (ED); misunderstanding instructions can put children at risk for ...adverse outcomes. Parents' ability to manage discharge instructions has not been examined before in a systematic review.
To perform a systematic review of the literature related to parental management (knowledge and execution) of inpatient and ED discharge instructions.
We consulted PubMed/Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane CENTRAL (from database inception to January 1, 2017).
We selected experimental or observational studies in the inpatient or ED settings in which parental knowledge or execution of discharge instructions were evaluated.
Two authors independently screened potential studies for inclusion and extracted data from eligible articles by using a structured form.
Sixty-four studies met inclusion criteria; most (
= 48) were ED studies. Medication dosing and adherence errors were common; knowledge of medication side effects was understudied (
= 1). Parents frequently missed follow-up appointments and misunderstood return precaution instructions. Few researchers conducted studies that assessed management of instructions related to diagnosis (
= 3), restrictions (
= 2), or equipment (
= 1). Complex discharge plans (eg, multiple medicines or appointments), limited English proficiency, and public or no insurance were associated with errors. Few researchers conducted studies that evaluated the role of parent health literacy (ED,
= 5; inpatient,
= 0).
The studies were primarily observational in nature.
Parents frequently make errors related to knowledge and execution of inpatient and ED discharge instructions. Researchers in the future should assess parental management of instructions for domains that are less well studied and focus on the design of interventions to improve discharge plan management.
The German Version of the Manchester Triage System (MTS) has found widespread use in EDs across German-speaking Europe. Studies about the quality criteria validity and reliability of the MTS ...currently only exist for the English-language version. Most importantly, the content of the German version differs from the English version with respect to presentation diagrams and change indicators, which have a significant impact on the category assigned. This investigation offers a preliminary assessment in terms of validity and inter-rater reliability of the German MTS.
Construct validity of assigned MTS level was assessed based on comparisons to hospitalization (general / intensive care), mortality, ED and hospital length of stay, level of prehospital care and number of invasive diagnostics. A sample of 45,469 patients was used. Inter-rater agreement between an expert and triage nurses (reliability) was calculated separately for a subset group of 167 emergency patients.
For general hospital admission the area under the curve (AUC) of the receiver operating characteristic was 0.749; for admission to ICU it was 0.871. An examination of MTS-level and number of deceased patients showed that the higher the priority derived from MTS, the higher the number of deaths (p<0.0001 / χ² Test). There was a substantial difference in the 30-day survival among the 5 MTS categories (p<0.0001 / log-rank test).The AUC for the predict 30-day mortality was 0.613. Categories orange and red had the highest numbers of heart catheter and endoscopy. Category red and orange were mostly accompanied by an emergency physician, whereas categories blue and green were walk-in patients. Inter-rater agreement between expert triage nurses was almost perfect (κ = 0.954).
The German version of the MTS is a reliable and valid instrument for a first assessment of emergency patients in the emergency department.
Over 9.6 million ED visits occur annually for abdominal pain in the US, but little is known about the medical outcomes of these patients based on demographics. We aimed to identify disparities in ...outcomes among children presenting to the ED with abdominal pain linked to race and SES.
Data from 4.2 million pediatric encounters of abdominal pain were analyzed from 43 tertiary US children's hospitals, including 2.0 million encounters in the emergency department during 2004-2011. Abdominal pain was categorized as functional or organic abdominal pain. Appendicitis (with and without perforation) was used as a surrogate for abdominal pain requiring emergent care. Multivariate analysis estimated likelihood of hospitalizations, radiologic imaging, ICU admissions, appendicitis, appendicitis with perforation, and time to surgery and hospital discharge.
Black and low income children had increased odds of perforated appendicitis (aOR, 1.42, 95% CI, 1.32- 1.53; aOR, 1.20, 95% CI 1.14 - 1.25). Blacks had increased odds of an ICU admission (aOR, 1.92, 95% CI 1.53 - 2.42) and longer lengths of stay (aHR, 0.91, 95% CI 0.86 - 0.96) than Whites. Minorities and low income also had lower rates of imaging for their appendicitis, including CT scans. The combined effect of race and income on perforated appendicitis, hospitalization, and time to surgery was greater than either separately.
Based on race and SES, disparity of health outcomes exists in the acute ED setting among children presenting with abdominal pain, with differences in appendicitis with perforation, length of stay, and time until surgery.
Objective
To examine the contributions of individual‐ and neighborhood‐level spatial access to care to the utilization of emergency departments (EDs) for preventable conditions through implementation ...of novel local spatial access measures.
Data Sources/Study Setting
Emergency department admissions data are from four HealthLNK member hospitals in Chicago from 2007 to 2011. Primary care physician office and clinic locations were obtained from the American Medical Association and the City of Chicago.
Study Design
Multilevel logit regression was used to model the relationship between individual‐ and neighborhood‐level attributes and preventable ED use.
Data Collection/Extraction Methods
Emergency department admissions data were classified based on the primary diagnosis for each encounter. Spatial access to care indices were generated in ArcGIS, and values were extracted at each ZIP code centroid to match patients' ZIP codes.
Principal Findings
Beyond sociodemographic factors such as gender and race, patients living in medically underserved areas (MUAs) and areas with lower spatial access to primary care clinics had higher odds of preventable ED use.
Conclusions
Preventable ED use can be associated with sociodemographic characteristics, as well as spatial access to primary care services. This study reveals potential for using local measures of spatial accessibility for preventable ED analyses.
IMPORTANCE: The coronavirus disease 2019 (COVID-19) pandemic, associated mitigation measures, and social and economic impacts may affect mental health, suicidal behavior, substance use, and violence. ...OBJECTIVE: To examine changes in US emergency department (ED) visits for mental health conditions (MHCs), suicide attempts (SAs), overdose (OD), and violence outcomes during the COVID-19 pandemic. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used data from the Centers for Disease Control and Prevention’s National Syndromic Surveillance Program to examine national changes in ED visits for MHCs, SAs, ODs, and violence from December 30, 2018, to October 10, 2020 (before and during the COVID-19 pandemic). The National Syndromic Surveillance Program captures approximately 70% of US ED visits from more than 3500 EDs that cover 48 states and Washington, DC. MAIN OUTCOMES AND MEASURES: Outcome measures were MHCs, SAs, all drug ODs, opioid ODs, intimate partner violence (IPV), and suspected child abuse and neglect (SCAN) ED visit counts and rates. Weekly ED visit counts and rates were computed overall and stratified by sex. RESULTS: From December 30, 2018, to October 10, 2020, a total of 187 508 065 total ED visits (53.6% female and 46.1% male) were captured; 6 018 318 included at least 1 study outcome (visits not mutually exclusive). Total ED visit volume decreased after COVID-19 mitigation measures were implemented in the US beginning on March 16, 2020. Weekly ED visit counts for all 6 outcomes decreased between March 8 and 28, 2020 (March 8: MHCs = 42 903, SAs = 5212, all ODs = 14 543, opioid ODs = 4752, IPV = 444, and SCAN = 1090; March 28: MHCs = 17 574, SAs = 4241, all ODs = 12 399, opioid ODs = 4306, IPV = 347, and SCAN = 487). Conversely, ED visit rates increased beginning the week of March 22 to 28, 2020. When the median ED visit counts between March 15 and October 10, 2020, were compared with the same period in 2019, the 2020 counts were significantly higher for SAs (n = 4940 vs 4656, P = .02), all ODs (n = 15 604 vs 13 371, P < .001), and opioid ODs (n = 5502 vs 4168, P < .001); counts were significantly lower for IPV ED visits (n = 442 vs 484, P < .001) and SCAN ED visits (n = 884 vs 1038, P < .001). Median rates during the same period were significantly higher in 2020 compared with 2019 for all outcomes except IPV. CONCLUSIONS AND RELEVANCE: These findings suggest that ED care seeking shifts during a pandemic, underscoring the need to integrate mental health, substance use, and violence screening and prevention services into response activities during public health crises.
We aim to describe the variability and identify gaps in preparedness and response to the coronavirus disease 2019 pandemic in European emergency departments (EDs) caring for children.
A ...cross-sectional point-prevalence survey was developed and disseminated through the pediatric emergency medicine research networks for Europe (Research in European Pediatric Emergency Medicine) and the United Kingdom and Ireland (Paediatric Emergency Research in the United Kingdom and Ireland). We aimed to include 10 EDs for countries with greater than 20 million inhabitants and 5 EDs for less populated countries, unless the number of eligible EDs was less than 5. ED directors or their delegates completed the survey between March 20 and 21 to report practice at that time. We used descriptive statistics to analyze data.
Overall, 102 centers from 18 countries (86% response rate) completed the survey: 34% did not have an ED contingency plan for pandemics and 36% had never had simulations for such events. Wide variation on personal protective equipment (PPE) items was shown for recommended PPE use at pretriage and for patient assessment, with 62% of centers experiencing shortage in one or more PPE items, most frequently FFP2 and N95 masks. Only 17% of EDs had negative-pressure isolation rooms. Coronavirus disease 2019–positive ED staff was reported in 25% of centers.
We found variation and identified gaps in preparedness and response to the coronavirus disease 2019 epidemic across European referral EDs for children. A lack in early availability of a documented contingency plan, provision of simulation training, appropriate use of PPE, and appropriate isolation facilities emerged as gaps that should be optimized to improve preparedness and inform responses to future pandemics.
To describe the epidemiology of foreign-body ingestions (FBIs) of children <6 years of age who were treated in US emergency departments from 1995 to 2015.
We performed a retrospective analysis using ...data from the National Electronic Injury Surveillance System for children <6 years of age who were treated because of concern of FBI from 1995 to 2015. National estimates were generated from the 29 893 actual cases reviewed.
On the basis of those cases, 759 074 children <6 years of age were estimated to have been evaluated for FBIs in emergency departments over the study period. The annual rate of FBI per 10 000 children increased by 91.5% from 9.5 in 1995 to 18 in 2015 (
= 0.90;
< .001). Overall, boys more frequently ingested foreign bodies (52.9%), as did children 1 year of age (21.3%). Most children were able to be discharged after their suspected ingestion (89.7%). Among the types of objects ingested, coins were the most frequent (61.7%). Toys (10.3%), jewelry (7.0%), and batteries (6.8%) followed thereafter. The rates of ingestions of those products also increased significantly over the 21-year period. Across all age groups, the most frequently ingested coin was a penny (65.9%). Button batteries were the most common batteries ingested (85.9%).
FBIs remain common in children <6 years of age, and their rate of ingestions has increased over time. The frequency of ingestions noted in this study underscores the need for more research to determine how best to prevent these injuries.
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