Examining perceptions of a telemedicine network for pediatric emergency medicine: a mixed-methods pilot study.

Background: Use of telemedicine for healthcare delivery in the emergency department can increase access to specialized care for pediatric patients without direct access to a children's hospital. Currently, telemedicine is underused in this setting. Objectives: This pilot research project aimed to evaluate the perceived effectiveness of a telemedicine program in delivering care to critically ill pediatric patients in the emergency department by exploring the experiences of parents/caregivers and physicians. Methods: Sequential explanatory mixed methods were employed, in which quantitative methods of inquiry were followed by qualitative methods. Data were collected through a post-used survey for physicians, followed by semi-structured interviews with physicians and parents/guardians of children treated through the program. Descriptive statistics were used to analyze the survey data. Reflexive thematic analysis was used to analyze interview data. Results: The findings describe positive perceptions of telemedicine for emergency department pediatric care, as well as barriers and facilitators to its use. The research also discusses implications for practice and recommendations for overcoming barriers and supporting facilitators when implementing telemedicine programming. Conclusion: The findings suggest that a telemedicine program has utility and acceptance among parents/caregivers and physicians for the treatment of critically ill pediatric patients in the emergency department. Benefits recognized and valued by both parents/caregivers and physicians include rapid connection to sub-specialized care and enhanced communication between remote and local physicians. Sample size and response rate are key limitations of the study.

Clinical outcomes in obese and normal-weight children undergoing ultrasound for suspected appendicitis.

BACKGROUND: Obesity constitutes an independent predictor for a nondiagnostic screening ultrasound (US) in suspected appendicitis. Furthermore, the imaging route consisting of the screening US with a second US if necessary has a significantly lower diagnostic accuracy in the obese children (83%) than their lean counterparts (93%). However, the effect of this association on clinical outcomes in the obese population is unknown. OBJECTIVES: In children presenting to the emergency department (ED) undergoing US for suspected appendicitis, the objective was to examine if there is a significant difference in the proportions of those with a "desirable outcome" in the obese group versus their normal-weight counterparts. METHODS: This was a reanalysis of a recent prospective cohort study conducted at a tertiary care pediatric ED. A consecutive sample of 263 previously healthy children 4-17 years of age undergoing screening US for suspected appendicitis was enrolled. Study patients were divided into obese (body mass index-for-age percentiles [BMI-FAP] ≥ 85%) and normal-weight groups. The main outcome was the proportion of children with the desirable outcome in the obese and normal-weight groups. Desirable outcomes for patients with a nondiagnostic screening US were defined as either 1) nonperforated appendicitis or alternate surgical diagnosis undergoing appropriate surgical procedure within 24 hours of assessment without a computed tomography (CT) scan or 2) no appendicitis, discharged from the ED within 24 hours without a CT scan. Secondary outcomes included hospitalization, CT imaging for any reason within 30 days of initial presentation, length of hospital stay, return visits, time to and length of surgery, and complications. RESULTS: Of the 263 patients, 76 (28.9%) were obese, and 187 had a normal weight. Ninety-nine children (37.6%) had appendicitis (obese = 24, normal-weight = 75). The desirable outcome was achieved in 46 (64.5%) of the obese patients versus 137 (73.3%) of the normal-weight children (95% confidence interval [CI] for the difference = -0.21 to 0.04). Compared to the normal-weight children, the obese children had similar hospitalization rates (44.7% vs. 45.5%), median length of hospital stay (20.5 hours vs. 23.0 hours), and return ED visit rates (11.8% vs. 9.1%). The median time to surgery (obese = 10.5 hours, normal-weight = 9.0 hours), complications (obese = 25%, normal-weight = 21.3%), perforations (obese = 33%, normal-weight = 31%), and length of surgery (obese 80 [±37] minutes, normal-weight 67 [±25] minutes) were also similar. The rate of CT within 30 days of initial presentation was higher in the obese compared to the normal-weight group (13/76 or 17.1% vs. 13/187 or 6.9%, 95% CI = 0.02 to 0.23). CONCLUSIONS: Previously healthy obese children undergoing screening US for suspected appendicitis experienced comparable clinical outcomes to their normal-weight counterparts. However, they were three times more likely to receive a CT scan during their investigation. These results argue for continuing current practice of using the screening US in this population, followed by a CT if clinically warranted upon reexamination.

Analgesia and sedation practices for incarcerated inguinal hernias in children.

In this study, the use of medications for analgesia and/or sedation for incarcerated inguinal hernia reductions in the emergency department was analyzed. A retrospective chart review was conducted for all patients presenting to a pediatric emergency department with incarcerated inguinal hernia from 2002 to 2005. A total of 99 children presented with incarcerated hernias during the study period. The median age was 11 months. Forty-four percent of children received medication for the procedure, of them 75% received parenteral and 25% oral or intranasal medications. Forty-five percent of children who received medication went through at least 1 hernia reduction attempt initially without medications. More than half the children with incarcerated inguinal hernias did not receive any medication for pain and/or sedation prior to hernia reduction. Guidelines for medication use for children with incarcerated inguinal hernias need to be developed.