Practice Pattern Variation in Test Ordering for Low-Acuity Pediatric Emergency Department Patients.

OBJECTIVES: Rising costs in healthcare have focused attention on interventions to optimize efficiency of patient care, including decreasing unnecessary diagnostic testing. The primary objective of this study was to determine the variability of laboratory and radiology testing among licensed independent providers (LIPs) with different training backgrounds treating low-acuity patients in a pediatric emergency department (PED). METHODS: We performed a retrospective review of the electronic health records of all encounters with patients 21 years or younger, triaged as low-acuity, visiting 2 urban, academic PEDs from January 2012 to December 2013. We calculated frequency of orders for specific tests, including complete blood counts, aerobic blood cultures, urine cultures, and chest radiographs. Bivariable analyses were used to measure associations of test ordering between these LIP dyad groups: physician versus nurse practitioner (NP); physicians with pediatric emergency medicine fellowship training (PEM) versus physicians without PEM training and physicians with at least 5 years since residency graduation versus less than 5 years. We used multivariable logistic regression to adjust for potential confounders, including ED location, trainee co-management, and patient characteristics. We also performed sensitivity analyses by location. RESULTS: There were 148,570 total encounters treated by 12 NPs and 144 physicians, of whom 60 were PEM physicians. Seventy-three physicians had 5 or more years of experience. Testing rates per patient encounter ranged from 0% to 40% for individual providers. In bivariable analyses, testing was more likely when the LIP was a physician (odds ratio [OR] = 1.2, 95% confidence interval = 1.1-1.2) or PEM trained (OR = 1.3, 1.2-1.3). In multivariable analyses, testing was more likely for encounters with PEM providers (adjusted OR [AdjOR] = 1.2, 1.1-1.3). A sensitivity analysis on a subset of encounters seen exclusively at our PED-based urgent care revealed that testing was also more likely for encounters seen by PEM physicians (AdjOR = 1.5, 1.4-1.7) and with NPs (AdjOR = 1.2, 1.1-1.4) compared with physicians. CONCLUSIONS: Our study identified substantial variation in test ordering patterns for LIPs treating low-acuity patients. There were significant differences in ordering practices between providers from different training backgrounds, most significantly when comparing PEM with non-PEM providers. Further research should examine interventions to standardize practice across disciplines.

Diagnosis of an Intraventricular Cyst Using Point-of-Care Cranial Ultrasound in the Pediatric Emergency Department.

A 2-month-old previously healthy male infant presents with 2 days of unusual eye movements and increased fatigue. During evaluation in the pediatric emergency department, point-of-care cranial ultrasound identified a cyst-like mass. Subsequent magnetic resonance imaging confirmed the presence of a cyst within the third ventricle causing obstructive hydrocephalus.

Evaluation of an after-hours call center: are pediatric patients appropriately referred to the emergency department?

BACKGROUND: There is concern that after-hours nurse telephone triage systems are overwhelming the emergency department (ED) with nonemergent pediatric referrals. OBJECTIVES: This study aimed to critically review a nonpediatric hospital-based call center with the aim of identifying the algorithms responsible for the majority of nonessential referrals. METHODS: This is a retrospective observational study performed at a tertiary medical care facility over 1 year. Telephone triage forms of children and adolescents younger than 18 years, exclusively referred by triage nurses using the Barton Schmitt protocols, were reviewed, and their ED course was evaluated by consulting the electronic medical record. "Essential" referrals to the ED were classified as presentations warranting immediate evaluation or referrals requiring "essential interventions" such as serum laboratory tests, imaging, complex procedures, intravenous medications, subspecialty consultation, or admission. RESULTS: A total of 220 patients were included in this study. Of these, 73 (33%) were classified as nonessential, whereas 147 (67%) were classified as essential. Nonessential patients were significantly younger compared with essential referrals (P < 0.05). They also had lower triage scores (P = 0.026) and shorter ED stays (P < 0.0001). The algorithms for "fever-3 months or older" (12.3%), "vomiting without diarrhea" (8.2%), "trauma-head" (8.2%), "headache" (6.8%), and "sore throat" (5.5%) were determined most likely to result in a nonessential referral. CONCLUSIONS: Our study identifies that a third of unnecessary pediatric visits to the ED occurred as a result of the nurse triage telephone system in question. We recommend review of the algorithms stated to reduce strain on local ED resources.

An update on pediatric hospital-based sedation.

PURPOSE OF REVIEW: The need for sedation for procedures performed outside the operating room has increased dramatically, and pediatric procedural sedation (PPS) is increasingly performed by practitioners who are not anesthesiologists. With 'sedationists' emerging from various specialties, there are differences in practice and guidelines with regards to presedation assessment, targeted depths of sedation, monitoring requirements, and the training required. Our aim is to identify some of the recent advances in PPS and to describe progress towards greater standardization of practice. RECENT FINDINGS: Several studies report attempts to optimize the efficacy of specific pharmaceuticals used in PPS. Ketamine, a dissociative agent, functions uniquely and requires its own sedation practice guidelines. Utilizing less invasive administration of sedation via transmucosal and inhaled routes is gaining popularity. Additionally, replacing subjective measurement of depths of the sedation continuum and the nonstandardized definitions of adverse events with alternatives based on physiological parameters and/or required rescue interventions is underway. Finally, the use of presedation family-centered counseling and adjuncts that provide visual and auditory distraction are enhancing pharmaceutical methods. SUMMARY: Further multispecialty collaboration and formation of greater consensus with regards to sedation practice are essential to the development of universal guidelines that optimize patient care.

Visits to the Pediatric Emergency Department for Eye Conditions Before and During the COVID-19 Pandemic.

INTRODUCTION: The use of the emergency department (ED) has been increasing, and many visits occur for non-urgent conditions. A similar trend was found among adult visits to the ED for ocular conditions. In this study we analyzed the impact of sociodemographic factors, presentation timing, and the COVID-19 pandemic on pediatric ED (PED) encounters for ophthalmologic conditions. It is important to identify the multifold factors associated with overutilization of the ED for non-urgent conditions. Caring for these patients in an outpatient clinical setting is safe and effective and could decrease ED crowding; it would also prevent delays in the care of other patients with more urgent medical problems and lower healthcare costs. METHODS: We retrospectively reviewed electronic health records of PED ocular-related encounters at two children's hospitals before (January 2014-May 2018) and during the COVID-19 pandemic (March 2020-February 2021). Encounters were categorized based on the International Classification of Diseases codes into "emergent," "urgent," and non-urgent" groups. We analyzed associations between sociodemographic factors and degrees of visit urgency. We also compared visit frequencies, degrees of urgency, and diagnoses between pre-pandemic and pandemic data. RESULTS: Pre-pandemic ocular-related PED encounters averaged 1,738 per year. There were highly significant sociodemographic associations with degrees of urgency in PED utilization. During the 12-month pandemic timeframe, encounter frequency contracted to 183. Emergent visits decreased from 21% to 11%, while the proportions of urgent and non-urgent encounters were mostly unchanged. The most common pre-pandemic urgent diagnosis was corneal abrasion (50%), while visual disturbance was most common during the pandemic (92%). During both time periods, eye trauma was the most frequent emergent encounter and conjunctivitis was the most common non-urgent encounter. CONCLUSION: Sociodemographic factors may be associated with different types of PED utilization for ocular conditions. Unnecessary visits constitute major inefficiency from a healthcare-systems standpoint. The marked decrease in PED utilization and differing proportions of ocular conditions encountered during the pandemic may reflect a decrease in incidence of many of those conditions by social distancing; these changes may also reflect altered parental decisions about seeking care.