Pediatric Emergency Department Visits Before and During the COVID-19 Pandemic - United States, January 2019-January 2022.

Emergency departments (EDs) in the United States remain a frontline resource for pediatric health care emergencies during the COVID-19 pandemic; however, patterns of health-seeking behavior have changed during the pandemic (1,2). CDC examined changes in U.S. ED visit trends to assess the continued impact of the pandemic on visits among children and adolescents aged 0-17 years (pediatric ED visits). Compared with 2019, pediatric ED visits declined by 51% during 2020, 22% during 2021, and 23% during January 2022. Although visits for non-COVID-19 respiratory illnesses mostly declined, the proportion of visits for some respiratory conditions increased during January 2022 compared with 2019. Weekly number and proportion of ED visits increased for certain types of injuries (e.g., drug poisonings, self-harm, and firearm injuries) and some chronic diseases, with variation by pandemic year and age group. Visits related to behavioral concerns increased across pandemic years, particularly among older children and adolescents. Health care providers and families should remain vigilant for potential indirect impacts of the COVID-19 pandemic, including health conditions resulting from delayed care, and increasing emotional distress and behavioral health concerns among children and adolescents.

EUAdb: A resource for COVID-19 test development and comparison.

Due to the sheer number of COVID-19 (coronavirus disease 2019) cases there is a need for increased world-wide SARS-CoV-2 testing capability that is both efficient and effective. Having open and easy access to detailed information about these tests, their sensitivity, the types of samples they use, etc. would be highly useful to ensure their reproducibility, to help clients compare and decide which tests would be best suited for their applications, and to avoid costs of reinventing similar or identical tests. Additionally, this resource would provide a means of comparing the many innovative diagnostic tools that are currently being developed in order to provide a foundation of technologies and methods for the rapid development and deployment of tests for future emerging diseases. Such a resource might thus help to avert the delays in testing and screening that was observed in the early stages of the pandemic and plausibly led to more COVID-19-related deaths than necessary. We aim to address these needs via a relational database containing standardized ontology and curated data about COVID-19 diagnostic tests that have been granted Emergency Use Authorizations (EUAs) by the FDA (US Food and Drug Administration). Simple queries of this actively growing database demonstrate considerable variation among these tests with respect to sensitivity (limits of detection, LoD), controls and targets used, criteria used for calling results, sample types, reagents and instruments, and quality and amount of information provided.

Appropriateness of emergency care use: a retrospective observational study based on professional versus patients' perspectives in Taiwan.

OBJECTIVE: The objectives of this study are to refine the measurement of appropriate emergency department (ED) use and to provide a natural observation of appropriate ED use rates based on professional versus patient perspectives. SETTING: Taiwan has a population of 23 million, with one single-payer universal health insurance scheme. Taiwan has no limitations on ED use, and a low barrier to ED use may be a surrogate for natural observation of users' perspectives in ED use. PARTICIPANTS: In 7 years, there were 1 835 860 ED visits from one million random samples of the National Health Insurance Database. MEASURES: Appropriate ED use was determined according to professional standards, measured by the modified Billings New York University Emergency Department (NYU-ED) algorithm, and further analysed after the addition of prudent patient standards, measured by explicit process-based and outcome-based criteria. STATISTICAL ANALYSES: The area under the receiver operating characteristic curve (AUC) was used to reflect the performance of appropriate ED use measures, and sensitivity analyses were conducted using different thresholds to determine the appropriateness of ED use. The generalised estimating equation model was used to measure the associations between appropriate ED use based on process and outcome criteria and covariates including sex, age, occupation, health status, place of residence, medical resources area, date and income level. RESULTS: Appropriate ED use based on professional criteria was 33.5%, which increased to 63.1% when patient criteria were added. The AUC, which combines both professional and patient criteria, was high (0.85). CONCLUSIONS: The appropriate ED use rate nearly doubled when patient criteria were added to professional criteria. Explicit process-based and outcome-based criteria may be used as a supplementary measure to the implicit modified Billings NYU-ED algorithm when determining appropriate ED use.

Implementation of a surgical screening system for urgent and emergent cases in a tertiary hospital. / Implementação de um modelo de triagem cirúrgica para casos urgentes em um hospital terciário.

OBJECTIVE: to evaluate the applicability of the "Timing of Acute Care Surgery" (TACS) color classification system in a tertiary public hospital of a developing country. METHODS: we conducted a longitudinal, retrospective study in a single center, from March to August 2016 and the same period in 2017. We opted for the selection of four surgical specialties with high demand for emergencies, previously trained on the TACS system. For comparisons with the previous classifications, we considered emergencies as reds and oranges and urgencies, as yellow, with an ideal time interval for surgery of one hour and six hours, respectively. RESULTS: non-elective procedures accounted for 61% of the total number of surgeries. The red, orange and yellow classifications were predominant. There was a significant improvement in the time before surgery in the yellow color after the TACS system. Day and night periods influenced the results, with better ones during the night. CONCLUSION: this is the first study to use the TACS system in the daily routine of an operating room. The TACS system improved the time of attendance of surgeries classified as yellow.

OBJETIVO: avaliar a aplicabilidade do sistema de classificação de cores "Timing of Acute Care Surgery" (TACS) em um hospital público terciário de um país em desenvolvimento. MÉTODOS: estudo longitudinal, retrospectivo, de um único centro, de março a agosto de 2016 e o mesmo período em 2017. Optou-se pela seleção de quatro especialidades cirúrgicas com alta demanda de urgências, as quais foram previamente treinadas sobre o sistema TACS. Para comparação com as classificações prévias de urgência e emergência, emergências foram consideradas como vermelhas e laranjas e urgências como amarelas, com intervalo de tempo ideal para cirurgia de uma hora e de seis horas, respectivamente. RESULTADOS: os procedimentos não eletivos representaram 61% do número total de cirurgias. As classificações vermelha, laranja e amarela foram predominantes. Houve melhora significativa do tempo para a cirurgia na cor amarela após o sistema TACS. Períodos diurnos e noturnos influenciaram os resultados, com melhores resultados durante o período noturno. CONCLUSÃO: este é o primeiro estudo que usou o sistema TACS no dia a dia de um centro cirúrgico, e demonstrou que o sistema TACS melhorou o tempo de atendimento das cirurgias classificadas como amarelas.

Impact of establishment of a color code in emergency caesareans in secondary health care maternity.

In 2008, a tertiary health care maternity set up a colour code organization for emergency caesarean to reduce the delay between decision and birth to thirty minutes. The aim of this study is to determine the feasibility of the implementation in secondary health care maternity. MATERIALS AND METHODS: This retrospective study was conducted in secondary health care maternity and it was divided in two phases: phase I corresponding to the period before the implementation of colour code and phase II, to the period after the implementation of colour code. All patients who had an emergency caesarean were included. Then, we compared the decision to birth delay between the two phases and the neonatal state. RESULTS: Two hundred and twenty patients were included (one hundred and thirteen for the first phase and one hundred and seven for the second). The rate of caesarean sections realized within thirty minutes was no different between two groups. Decision to birth delay is variable and tends to decrease between two phases (-7 min for orange code, p = 0.91; and -15 min for red code, p = 0.0769). The medium pH is the same in both groups (7.30, p = 0.22) and the rate of transfer in neonatology is 29% for the first group and 13% in the second (p = 0.004) CONCLUSION: This protocol has resulted in better care for patients who had an emergency caesarean section. Two elements are to be noticed as follows: a reduction of decision to birth delay for extremely emergency caesarean (p = 0.0769) and less transfer in neonatology (p = 0.004).

Implementação de um modelo de triagem cirúrgica para casos urgentes em um hospital terciário / Implementation of a surgical screening system for urgent and emergent cases in a tertiary hospital

RESUMO Objetivo: avaliar a aplicabilidade do sistema de classificação de cores "Timing of Acute Care Surgery" (TACS) em um hospital público terciário de um país em desenvolvimento. Métodos: estudo longitudinal, retrospectivo, de um único centro, de março a agosto de 2016 e o mesmo período em 2017. Optou-se pela seleção de quatro especialidades cirúrgicas com alta demanda de urgências, as quais foram previamente treinadas sobre o sistema TACS. Para comparação com as classificações prévias de urgência e emergência, emergências foram consideradas como vermelhas e laranjas e urgências como amarelas, com intervalo de tempo ideal para cirurgia de uma hora e de seis horas, respectivamente. Resultados: os procedimentos não eletivos representaram 61% do número total de cirurgias. As classificações vermelha, laranja e amarela foram predominantes. Houve melhora significativa do tempo para a cirurgia na cor amarela após o sistema TACS. Períodos diurnos e noturnos influenciaram os resultados, com melhores resultados durante o período noturno. Conclusão: este é o primeiro estudo que usou o sistema TACS no dia a dia de um centro cirúrgico, e demonstrou que o sistema TACS melhorou o tempo de atendimento das cirurgias classificadas como amarelas.

ABSTRACT Objective: to evaluate the applicability of the "Timing of Acute Care Surgery" (TACS) color classification system in a tertiary public hospital of a developing country. Methods: we conducted a longitudinal, retrospective study in a single center, from March to August 2016 and the same period in 2017. We opted for the selection of four surgical specialties with high demand for emergencies, previously trained on the TACS system. For comparisons with the previous classifications, we considered emergencies as reds and oranges and urgencies, as yellow, with an ideal time interval for surgery of one hour and six hours, respectively. Results: non-elective procedures accounted for 61% of the total number of surgeries. The red, orange and yellow classifications were predominant. There was a significant improvement in the time before surgery in the yellow color after the TACS system. Day and night periods influenced the results, with better ones during the night. Conclusion: this is the first study to use the TACS system in the daily routine of an operating room. The TACS system improved the time of attendance of surgeries classified as yellow.

A traffic-light coding system to organize emergency surgery across surgical disciplines.

BACKGROUND: Emergency surgery is associated with night-time procedures and disruption of elective surgery. An analysis was undertaken of the effect of classifying emergency operations uniformly with a three-tier urgency colour code and the use of dedicated daytime operating rooms. METHODS: Observed changes from 2001 to 2012 in the number, timing and ability to meet the urgency-designated colour code deadline were retrieved from the computer-based operating theatre organization system for all emergency operations. RESULTS: The number of emergency operations performed annually ranged from 3330 to 4341, with an increasing trend. The proportion of night-time emergency operations decreased from 27.4 per cent (2563 of 9347) before to 23.5 per cent (7731 of 32,959) after introduction of the colour coding system in 2004 (χ2 = 61.94, 1 d.f., P < 0.001). In 2007, owing to long preoperative delays in patients with acute appendicitis and acute cholecystitis, colour codes for these patients were upgraded from 'orange' to 'red' and from 'yellow' to 'orange' respectively. The proportion of patients operated on with a red code before and after this change increased from 45.2 per cent (5831 of 12,907 operations) to 62.7 per cent (13,020 of 20,778 operations; χ2 = 986.99, 1 d.f., P < 0.001). In 2012, the office-hours raw utilization time for the principal emergency operation theatre was 85.4 per cent. CONCLUSION: The structural separation of elective and emergency surgery, the use of dedicated daytime operating theatres and the implementation of a universal classification of emergency operations reduced night-time surgery, improved the efficiency of operating theatre utilization during daytime, shortened preoperative delay in patients requiring urgent surgery, and enabled monitoring and corrective actions for providing emergency surgery services.

Emergency Department Overcrowding in Turkey: Reasons, Facts and Solutions.

INTRODUCTION: The purpose of this study was to determine the factors affecting the long waiting times of the patients in a university hospital. METHODS: This study included 3000 of the adults above 18 years and pediatric trauma patients under 18 years who applied to emergency department between February 2009 and April 2009. The examination period of the physician, length of stay, length of hospitalization, waiting times for hospitalization and follow up times in the emergency department were recorded. Moreover, the patients were divided into four groups according to the reasons for waiting. RESULTS: In our study, the time period between 4 pm-12 pm was determined as the busiest time for the applications. Average length of stay in the emergency department for 3000 patients was 146.7±160.2 minutes. The length of stay for the patients consulted was longer than the length of stay for the ones who were not consulted. Because of the fact that our hospital did not have appropriate bed capacity, 41.1% of the patients waited less than two hours, 13. 4% of the patients waited more than 8 hours. It was also found that the waiting times of the Group two patients (206,7±145,2 minutes) was longer than Group one (95,5±73,9 minutes) patients and the waiting times of Group three patients (470,7±364,7 minutes) was longer than Group one patients. CONCLUSIONS: In conclusion, cooperation of the managers, relevant departments and a multidisciplinary approach are necessary to achieve the goals to reduce overcrowding in the emergency departments.

[Color-codes implementation shortens the decision-to-delivery interval of emergency C-sections]. / La mise en oeuvre des codes "couleur" réduit le délai décision-naissance des césariennes urgentes.

OBJECTIVES: To assess the efficiency of a new tool designed to shorten the decision-to-delivery interval (DDI) for emergency C-sections (CS). MATERIALS AND METHODS: DDI comparisons during three 6-month periods in a third level maternity. In stage A we evaluated the spontaneous DDI, in stage B the DDI was measured after the introduction of a color-code communication tool related to the degree of urgency for CS (amber code indicated urgent CS with an ideal DDI of 30 min and red code for very urgent CS with an ideal DDI of 15 min). In stage C we assessed the impact of the color-codes related protocols implementation. RESULTS: Two hundred and fifty-three C-sections were included (211 urgent CS and 42 very urgent CS). Mean DDI decreased significantly from 42 min to 24 min between period A and period C for amber codes (corresponding to 43.2% and 82.1% of the objectives respectively) and from 24.9 min to 10.7 min for red codes (20% et 83.3% of the objectives). CONCLUSION: This study suggests that color-codes and their related application protocols significantly shorten the DDI during the evaluation periods.

2009 OPPS rule is good news for EDs.

For once, the final Outpatient Prospective Payment System payment rule issued by the Centers for Medicare & Medicaid Services generally has been praised by emergency medicine observers. There are, however, some new wrinkles you should be aware of, because they could save - or cost - you money: A separate coding category has been established for EDs that are not open 24/7. The payment rates are lower than those in full-time EDs, except for Level 5 visits. Imaging procedures have been grouped into five milies," and multiple tests on the same patient within the same family will be reimbursed as if only a single test was performed. Visits coded for "trauma response with critical care" will be reimbursed at a rate nearly three times as high as last year's rate.

Comparison of different methods of risk stratification in urgent and emergency surgery.

BACKGROUND: The aim was to compare a number of risk scoring systems prospectively in a cohort of patients who underwent non-elective surgery. METHODS: This was a cohort study of 2349 consecutive patients who had urgent or emergency surgery in a district general hospital in the UK. All patients were scored prospectively using the Revised Goldman Cardiac Risk Index (RGCRI), Portsmouth modification of the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM), Surgical Risk Score (SRS) and Biochemistry and Haematology Outcome Models (BHOM). Actual 30-day and 1-year survival rates were compared with the predicted outcomes using receiver-operator characteristic (ROC) curves and Hosmer-Lemeshow analysis. RESULTS: Some 141 patients (6.0 per cent) died within 30 days of operation. This increased to 254 (10.8 per cent) by 1 year. The area under the ROC curve for death within 30 days was 0.90 for P-POSSUM, 0.85 for SRS, 0.84 for BHOM and 0.73 for RGCRI. Only the first three risk scores were able to discriminate accurately within the groups (area under ROC curve over 0.8), with no significant variation between expected and observed mortality rates confirmed by Hosmer-Lemeshow analysis. Similar results were found for the ability of each score to predict outcome at 1 year. CONCLUSION: P-POSSUM, SRS and BHOM scoring systems were all able to predict outcome after emergency and urgent surgery, but the SRS had the advantage of ease of calculation. BHOM requires only the most commonly available blood test data and the computer holding these data can easily perform the calculation.

Medicare's ambulance fee schedule dispatched.

Ambulance fees vary with the level of service and length of the beneficiary's trip. New fee schedule is expected to trim Medicare spending. Higher fees have been implemented for rural transports and air ambulance services. Lower fees have been implemented for urban transports. Providers and suppliers must revise chargemasters, policies, and procedures.

Impact of a tornado on a community hospital.

A significant tornado passed through the Oklahoma City metropolitan area on May 3,1999. This study was undertaken at St Michael Hospital (Oklahoma City, Okla) to describe the impact on a community hospital's emergency department close to the tornado strike zone. Cases were defined as patients receiving diagnostic procedures, care, and interventions at the study hospital's emergency department for injuries related to the tornado. Medical records were abstracted and entered into a custom database; descriptive analysis was done using Microsoft Excel 97. A total of 147 patients met the study criteria, with an admission rate of 31 (21%) [corrected] of 147 patients (6 [19.4%] of 31 to the operating room, 4 [12.9%] of 31 to the intensive care unit, and 21 [67.7%] [corrected] of 31 to ward beds). In addition, 4 (2.7%) of the 147 patients were transferred to tertiary-care facilities (3 pediatric patients with head injuries and 1 adult patient with spinal cord injury). Complex soft tissue wounds, head injuries, and fractures were the most common diagnoses. The number of head-injured patients arriving alive to the emergency department was higher than expected. Most soft tissue wounds were closed primarily in the emergency department. The authors recommend that preexisting referral patterns for trauma and specialty care should be a part of the overall disaster plans for community hospitals.

Influence of trauma system implementation on process of care delivered to seriously injured patients in rural trauma centers.

BACKGROUND: Statewide trauma systems are implemented by health care policy makers whose intent is to improve the process of care delivered to seriously injured patients. In Oregon, Advanced Trauma Life Support (ATLS) training was mandated for all physicians employed in the emergency department of trauma centers. The purpose of this study was to test the hypothesis that mandatory ATLS training favorably influenced processes of care. METHODS: Seriously injured patients treated at 9 rural Level 3 and Level 4 hospitals were studied before (PRE) and after (POST) implementation of Oregon's trauma system. The processes of care evaluated on the basis of chart review were 20 diagnostic and therapeutic interventions advocated in the ATLS course. A cumulative process score (CPS) between 0 and 1 was assigned on the basis of the processes of care delivered. A CPS of 1 indicated optimal process of care. RESULTS: Mean CPS for 506 PRE period patients (0.44 +/- 0.27) was significantly lower than the mean CPS for 512 POST period patients (0.57 +/- 0.27) with an unpaired t test (P <.001). For the subgroup with injury severity score of 16 to 34, the mean CPS of survivors (0.67 +/- 0.19) was significantly higher than the mean CPS of decedents (0.57 +/- 0.25). CONCLUSIONS: Process of care for seriously injured patients improved after categorization of rural trauma centers in Oregon. Evidence shows improved process of care may have benefitted patients with serious but survivable injuries. Measurement of process of care is an alternative to mortality analysis as an indication of the quality of care.

Emergency department impact of the Oklahoma City terrorist bombing.

STUDY OBJECTIVE: To collect descriptive epidemiologic injury data on patients who suffered acute injuries after the April 19, 1995, Oklahoma City bombing and to describe the effect on metropolitan emergency departments. METHODS: A retrospective review of the medical records of victims seen for injury or illness related to the bombing at 1 of the 13 study hospitals from 9:02 AM to midnight April 19, 1995. Rescue workers and nontransported fatalities were excluded. RESULTS: Three hundred eighty-eight patients met inclusion criteria; 72 (18.6%) were admitted, 312 (80.4%) were treated and released, 3 (.7%) were dead on arrival, and 1 had undocumented disposition. Patients requiring admission took longer to arrive to EDs than patients treated and released (P =.0065). The EDs geographically closest to the blast site (1.5 radial miles) received significantly more victims than more distant EDs (P <.0001). Among the 90 patients with documented prehospital care, the most common interventions were spinal immobilization (964/90, 71.1%), field dressings (40/90, 44.4%), and intravenous fluids (32/90, 35.5%). No patients requiring prehospital CPR survived. Patients transported by EMS had higher admission rates than those arriving by any other mode (P <.0001). The most common procedures performed were wound care and intravenous infusion lines. The most common diagnoses were lacerations/contusion, fractures, strains, head injury, abrasions, and soft tissue foreign bodies. Tetanus toxoid, antibiotics, and analgesics were the most common pharmaceutical agents used. Plain radiology, computed tomographic radiology, and the hospital laboratory were the most significantly utilized ancillary services. CONCLUSION: EMS providers tended to transport the more seriously injured patients, who tended to arrive in a second wave at EDs. The closest hospitals received the greatest number of victims by all transport methods. The effects on pharmaceutical use and ancillary service were consistent with the care of penetrating and blunt trauma. The diagnoses in the ED support previous reports of the complex but often nonlethal nature of bombing injuries.