Characterizing pediatric high frequency users of California emergency departments.

OBJECTIVE: Emergency department (ED) utilization has increased for the last several decades. Despite a focus on adult frequent ED users, little research has examined pediatric frequent ED users. The purpose of this study was to assess pediatric ED utilization in California and to describe those identified as frequent ED users. METHODS: This was a retrospective multi-facility study of ED visits by children 1-17 years of age using statewide data from the California Office of Statewide Health Planning and Development. Patients were classified into utilization groups by the number of ED visits in a one-year period prior to their last visit in 2016: occasional (1-5 visits) vs. frequent (>5 visits). Differences in patient characteristics were compared between occasional and frequent users. RESULTS: There were 690,130 patients between 1 and 17 years of age with 1,238,262 visits during the study period. Children with ≥6 visits (2.3%) accounted for 9.3% of all visits. 67% of frequent users had no visits to a pediatric ED. Over 40% (41.4%) of frequent users visited 2 or more hospitals, compared to 7.7% of occasional users. In multivariate analysis, the characteristics with the largest associations with frequent ED use were age, payer, and being admitted/transferred. CONCLUSIONS: The majority of pediatric frequent users do not seek care in pediatric EDs. Age, prior admission, and Medicare/Medicaid appear to have the largest associations with pediatric patient frequent ED utilization.

Building Affordable, Durable, Medium-fidelity Ballistic Gel Phantoms for Ultrasound-guided Nerve Block Training.

Ultrasound phantoms - alternatives to live human tissue - give learners the opportunity to practice ultrasound-guided regional anesthesia without introducing undue risk to patients. Gelatin-based phantoms provide educators with durable and reusable task trainers; however, commercially available gel-based phantoms are expensive. Here, we investigate the production of durable, low-cost, ballistic gel-based ultrasound phantoms for median, femoral, suprainguinal fascia iliaca plane, and serratus anterior plane nerve blocks, as well as a methodology for producing a phantom for any ultrasound-guided nerve block procedure. Computer-aided design (CAD) software was utilized to design four phantoms replicating the anatomy of median, femoral, suprainguinal fascia iliaca plane, and serratus anterior plane nerve blocks, including relevant landmarks and tissue planes. Plastic models of the desired tissue planes were 3D printed and used to create silicone molds. Ballistic gel was melted and mixed with flour and dye to create a liquid, echogenic ballistic gel, which was poured into the silicone molds. Vessels were simulated by creating negative space in the ballistic gel using metal rods. Nerves were simulated using yarn submerged in ultrasound gel. Simulated bones were designed using CAD and 3D printed. Ballistic gel is a versatile, durable medium that can be used to simulate a variety of tissues and can be melted and molded into any shape. Under ultrasound, these phantoms provide realistic tissue planes that represent the borders between different layers of skin, muscle, and fascia. The echogenicity of the muscle tissue layers, nerves, vessels, and bones is realistic, and bones have significant posterior shadowing as would be observed in a human subject. These phantoms cost $200 each for the first phantom and $60 for each subsequent phantom. These phantoms require some technical skill to design, but they can be built for just 4% of the cost of their commercial counterparts.