Hyperkalemia in a Hemolyzed Sample in Pediatric Patients: Repeat or Do Not Repeat?

OBJECTIVE: The aim of the study is to analyze whether repeat testing is necessary in healthy children presenting to a pediatric emergency department (ED) who are found to have hyperkalemia on a hemolyzed specimen. METHODS: A 5-year retrospective analysis of pediatric ED patients found to have elevated potassium values on laboratory testing of a sample reported to be hemolyzed. All patients aged 0 to 17 years who had an elevated potassium level after an intravenous draw resulted from a serum sample that was reported as hemolyzed during an ED visit were included in the study. RESULTS: One hundred eighty-seven patients with some degree of both hemolysis and hyperkalemia were included in the final analysis. The median age was 1.9 years of age. The most common race among all patients was White, followed by African American, and Asian. One hundred forty-five children had repeat sampling for hemolyzed hyperkalemia, 142 children, 97.9% (95% confidence interval, 95.6%-100%) had a normal potassium on repeat and 3 children, 2.1% (95% confidence interval, 0.0%-4.4%) had true hyperkalemia. The frequency of true hyperkalemia in our study population was 2% (3/145). All 3 of these patients had underlying conditions that would appropriately have raised clinician suspicion for hyperkalemia. CONCLUSIONS: It may be unnecessary to obtain repeat samples to confirm normal potassium in a hemolyzed sample with normal blood urea nitrogen and creatinine.

Providing a Second Opinion to Dr. Google with the WWW Framework.

While clinicians are often aware that their patients seek second opinions, they are rarely taught specific skills for how to effectively communicate with patients when they are the ones providing that second opinion. The nuances of these skills are amplified when the second opinion being provided is to the ubiquitous (and often anonymous) Dr. Google. In this perspective, the authors share an approach for discussing a patient's pre-visit health-related internet findings. After emphasizing the importance of setting the stage, they describe the WWW Framework which proposes "waiting" before responding with data, getting to the "what" of the patient's search, and "working together" to negotiate a plan. This stepwise approach is designed to provide psychological safety, build a therapeutic alliance, and empower collaborative treatment planning.

Breastfeeding Among Pediatric Emergency Physicians: Rates, Barriers, and Support.

OBJECTIVES: Physician mothers are at risk for early cessation of breastfeeding, in part because of challenges associated with returning to work. Given the inherent unpredictability of emergency medicine practice, we hypothesized that pediatric emergency medicine (PEM) physicians would face unique challenges in continuing breastfeeding while working in their field. The aims of this study were to determine the 6-month breastfeeding rates of PEM physicians, gain insight into their experiences expressing breast milk while working in pediatric emergency departments, and determine factors that support or discourage successful breastfeeding. METHODS: This study was a cross-sectional survey of members of the American Academy of Pediatrics Section on Emergency Medicine via its quarterly membership survey program. Separate survey pathways were developed for respondents who had ever breastfed and those who had not. RESULTS: One hundred ninety-three responded; 91 had breastfed, and 102 had not. Of those who breastfed, 90% did so for 6 months or longer. Mean (SD) duration was 12.5 (7.1) months (range, 2-48 months). Of those who expressed milk at work, only 7.6% felt they "always" had sufficient time to pump; 32% felt they "always" had what they considered to be an appropriate location to pump. Breastfeeding duration rate of at least 6 months was higher for those (66%) who "sometimes" to "always" had access to what they felt were appropriate locations to pump than for those (34%) who "never" or "occasionally" did (98 vs 85%, P = 0.048). Eighty-six percent of respondents who had never breastfed reported being "very supportive" of expressing milk at work. CONCLUSIONS: Breastfeeding PEM physicians have high 6-month breastfeeding rates, and many express milk at work. Although colleagues report being supportive, barriers of perceived lack of sufficient time to pump and appropriate pumping locations remain.

Ondansetron Prescription for Home Use in a Pediatric Emergency Department.

OBJECTIVES: Ondansetron has been shown to decrease admission rate and the need for intravenous fluids among pediatric emergency department (ED) patients with acute gastroenteritis, but there is limited evidence regarding its use after ED discharge. This study describes prescribing patterns for ondansetron and assesses the effects of ondansetron home prescription on rate of return. METHODS: Data were gathered from the electronic health record on 2 separate but overlapping groups of patients seen in a pediatric ED from 2012 to 2014. The Gastroenteritis Group included all patients with a discharge diagnosis of gastroenteritis by International Classification of Diseases, Ninth Revision, code. The All Ondansetron Group included any child prescribed ondansetron at discharge. Patterns of ondansetron use and 3- and 7-day ED return rate were assessed for both groups. Discharge diagnosis was evaluated for the All Ondansetron Group. RESULTS: A total of 996 patients with acute gastroenteritis were identified during the study period. Of these, 76% received ondansetron in the ED, and 71% were discharged with prescriptions for ondansetron. Seven-day ED return rates were similar between groups (6% with prescription, 5% without, P = 0.66). A total of 2287 patients received home prescriptions for ondansetron. Fifty-four percent of these patients' discharge diagnoses were classed as gastrointestinal complaints, 14% other infectious conditions, 9% respiratory, and 4% injuries. Their return rate was 6%. There was wide variation in the number of doses prescribed. CONCLUSIONS: Home-use ondansetron is widely prescribed in this urban academic pediatric ED for a variety of indications, without effect on 3- or 7-day ED return. Further prospective studies are necessary to determine the efficacy of this practice.

A Comparison of the Efficacy of Enema Solutions in Pediatric Emergency Department Patients.

BACKGROUND: Children presenting to pediatric emergency departments (EDs) are frequently given enemas for relief of constipation symptoms; there is very little literature guiding solution selection. OBJECTIVE: Our aim was to assess and compare the efficacy of the various enema solutions used in a pediatric ED, including the "pink lady," a previously unreported compounded combination of docusate, magnesium citrate, mineral oil, and sodium phosphate. METHODS: We identified all children who received any enema over a 5-year period in an urban, quaternary care pediatric ED for inclusion in the study via electronic record review. Physician investigators retrospectively reviewed routine visit documentation to confirm the type and dosage of enema and assess comorbidities, indications, efficacy, and side effects. Subjective descriptions of output were classified as none, small, medium, or large by reviewer consensus. RESULTS: There were 768 records included. Median age was 6.2 years (interquartile range 3.3-10.3 years). Solutions used were sodium phosphate (n = 396), pink lady (n = 198), soap suds (n = 160), and other (n = 14). There was no significant difference in output by solution type (p = 0.88). Volume delivered was highest for pink lady, with no significant association between volume delivered and output (p = 0.48). Four percent of patients had side effects. Soap suds had a significantly higher rate of side effects (10.6%; p = 0.0003), primarily abdominal pain. CONCLUSIONS: There was no significant difference in reported stool output produced by sodium phosphate, soap suds, and pink lady enemas in children treated in an ED. Further study via randomized controlled trials would be beneficial in guiding selection of enema solution.

The Use of a Triage-Based Protocol for Oral Rehydration in a Pediatric Emergency Department.

BACKGROUND: Guidelines recommend oral rehydration therapy (ORT) and avoidance of laboratory tests and intravenous fluids for mild to moderate dehydration in children with gastroenteritis; oral ondansetron has been shown to be an effective adjunct. OBJECTIVES: The aim of this study was to determine if a triage-based, nurse-initiated protocol for early provision of ondansetron and ORT could safely improve the care of pediatric emergency department (ED) patients with symptoms of gastroenteritis. METHODS: This study evaluated a protocol prompting triage nurses to assess dehydration in gastroenteritis patients and initiate ondansetron and ORT if indicated. Otherwise well patients aged 6 months to 5 years with symptoms of gastroenteritis were eligible. Prospective postintervention data were compared with retrospective, preintervention control subjects. RESULTS: One hundred twenty-eight (81 postintervention and 47 preintervention) patients were analyzed; average age was 2.1 years. Ondansetron use increased from 36% to 75% (P < 0.001). Time to ondansetron decreased from 60 minutes to 30 minutes (P = 0.004). Documented ORT increased from 51% to 100% (P < 0.001). Blood testing decreased from 37% to 21% (P = 0.007); intravenous fluid decreased from 23% to 9% (P = 0.03). Fifty-two percent of postintervention patients were discharged with prescriptions for ondansetron. There were no significant changes in ED length of stay, admissions, or unscheduled return to care. CONCLUSIONS: A triage nurse-initiated protocol for early use of oral ondansetron and ORT in children with evidence of gastroenteritis is associated with increased and earlier use of ondansetron and ORT and decreased use of IV fluids and blood testing without lengthening ED stays or increasing rates of admission or unscheduled return to care.

Implementation of an Electronic Clinical Decision Support Tool for Pediatric Appendicitis Within a Hospital Network.

OBJECTIVES: Computed tomography (CT) has been widely used in the evaluation of children with suspected appendicitis, but concerns about ionizing radiation have increased interest in ultrasound for these patients. We sought to assess the effectiveness of an appendicitis electronic clinical decision support (E-CDS) system in increasing ultrasound and decreasing CT use in children evaluated in emergency departments (EDs) for suspected appendicitis. METHODS: This was a preintervention and postintervention analysis of an E-CDS implemented into an electronic health record system shared by an academic, tertiary-care children's hospital and a community hospital. The tool consisted of a structured order set with embedded clinical advice and a link to a Web site. Emergency department patients aged 3 to 18 years with suspected appendicitis were reviewed retrospectively. Imaging use was assessed 3 months before and 6 months after implementation of the intervention. RESULTS: Three hundred twenty-seven patients were identified, 211 at postintervention; 80% were seen in the community ED. Among community ED patients with imaging, ultrasound use increased (36%-51%, P = 0.049), and CT scan use decreased (81%-66%, P = 0.044) in the postintervention period, with no change in complications or safety outcomes. No difference was found in ultrasound rate (100%-97%, P = 1.000) or CT scan rate (13%-10%, P = 1.000) among children's ED patients with imaging. CONCLUSIONS: An E-CDS can effectively decrease CT scanning and increase use of ultrasound in children with suspected appendicitis in a community hospital ED. Electronic clinical decision support may be an effective method of disseminating pediatric best practices from a children's hospital to affiliated community EDs.

Community Primary Care Provider Preferences for Emergency Department Follow-up Recommendations: A Regional Study.

BACKGROUND: Children who present to emergency departments (EDs) for care are frequently advised to follow up with their primary care providers (PCPs) after discharge; little is known about whether PCPs agree that follow-up advised by EDs is appropriate for their patients. OBJECTIVES: The aims of this study were to determine PCP preferences for follow-up recommendations given to their pediatric patients at the time of ED visits and to compare these preferences to reported emergency medicine provider (EMP) practice. METHODS: This was an online survey of PCPs and EMPs in a regional health system assessing preferred timing for ED follow-up recommendations for 15 common pediatric conditions and whether the follow-up should be definite or contingent. RESULTS: Ninety PCPs and 36 EMPs responded to the survey. In patients with community-acquired pneumonia, probability of recommending follow-up after 5 or more days was 33% in PCPs and 8% in EMPs (P = 0.001). In all conditions with significant differences, PCPs favored longer follow-up. In upper respiratory tract infection and acute otitis media, PCPs had a higher probability than EMPs of selecting as-needed versus definite follow-up (P = 0.0002 and P = 0.01, respectively). In asthma, concussion, and pneumonia, PCPs had a significantly lower probability of selecting as-needed follow-up than EMPs. CONCLUSIONS: In this regional survey, PCPs preferred longer times between ED visit and follow-up than EMPs for a number of conditions. Differences were also found in preference for as-needed or definite follow-up, varying by condition. These discrepancies could result in overuse or underuse of clinic resources, suggesting a possible quality improvement target for emergency medicine practice.

Reducing pediatric CT usage through web-based education.

A grant from the AHRA and Toshiba Putting Patients First program enabled Fairview Health System in Minneapolis, MN to launch an interactive education website which provides best practice information for CT usage in head trauma and appendicitis cases. The website, PEMguidelines.org contains educational sections geared toward both clinicians and patients and families. The site provides evidenced based guidelines for the management of head trauma and appendicitis. PEMguidelines.org was rolled out in 2012 as part of a three pronged intervention strategy. A linkto the website was included in new clinical order-sets within the Fairview electronic health system. Clinical decision support aids were also embedded in the medical record system. Fairview held provider education sessions for ED physicians and staff to introduce and promote the new approach. Results from a six month period after the initial roll out indicate a decrease of 15% in abdominal CT scans for suspected appendicitis cases, while the numbers of missed cases did not increase.This initial evidence supports the effectiveness of this multilevel strategy in improving the safety and cost-effectiveness of pediatric CT use in diagnosis of appendicitis.

Laypeople's (Mis)Understanding of Common Medical Acronyms.

OBJECTIVES: Abbreviations are often used in medicine yet may be a source of confusion for patients and their families. We aimed to determine the general public's understanding of commonly used medical acronyms. METHODS: For this cross-sectional study, we surveyed state fair visitors regarding their understanding of 5 common medical acronyms. An electronic survey was administered to a volunteer sample of adults who spoke and read English and who had never trained to work in medicine or nursing. Free-text responses were coded as correct, partially correct, or incorrect by 2 independent researchers, adding a third researcher if consensus was not reached. Analysis methods included descriptive statistics, Fisher exact tests, and multivariable logistic regression models. RESULTS: We recruited 204 volunteers (55% female; mean age 43 years; 67% had a bachelor's degree or higher). ED (emergency department) was correctly defined by 32%, PCP (primary care provider/physician) by 18%, CBC (complete blood count) by 14%, and PRN (as needed) and NPO (nothing by mouth) by 13% each. Female gender was associated with higher odds of correctly understanding NPO (odds ratio, 3.11; 95% confidence interval, 1.18-8.21; P = .02); older age was associated with higher odds of understanding PRN (odds ratio, 1.03; 95% confidence interval, 1.00-1.05; P = .04). Education level was not found to correlate significantly with successful explanation of any tested acronym. CONCLUSIONS: Medical acronyms are a predictable source of miscommunication. In this large cross-sectional study, none of the acronyms evaluated was understood correctly by more than one-third of adults. Clinicians should avoid using acronyms with patients and families to minimize confusion.

Jargon Be Gone - Patient Preference in Doctor Communication.

While it has been shown that healthcare providers often use medical jargon, less is known about how patients prefer their clinicians communicate. This mixed-methods study aimed to better understand the general public's preference in healthcare communication. A volunteer cohort of 205 adult attendees at the 2021 Minnesota State Fair was presented a survey with two scenarios at a doctor's office sharing the same information: one using medical terminology and one using simpler, jargon-free language. Survey participants were asked which doctor they preferred, to describe each doctor, and to explain why they believe that doctors may use medical terminology. Common descriptive themes for the jargon-using doctor included that this doctor caused confusion, was too technical, and was uncaring, while the doctor who spoke without jargon was perceived as a good communicator, caring/empathetic, and approachable. Respondents perceived a range of reasons why doctors use jargon, from not recognizing they are using words that are not understood to trying to make themselves feel more important. Overall, 91% of survey respondents preferred the doctor who communicated without medical jargon.

What's in a name? Laypeople's understanding of medical roles and titles.

BACKGROUND: Physicians regularly use jargon in patient communication, which can lead to confusion and misunderstanding. OBJECTIVE: To assess the general public's understanding of names and roles of medical specialties and job seniority titles. DESIGNS: Volunteer participants completed an electronic survey, filling-in-the-blanks for 14 medical specialties (e.g., "pediatricians are doctors who take care of _____"), and ranked physician titles in order of experience (medical student, intern, senior resident, fellow, attending). SETTING: The 2021 Minnesota State Fair. PARTICIPANTS: Volunteers >18 years old without medical or nursing training. MAIN OUTCOME AND MEASURES: We summarized responses with descriptive statistics. Two researchers coded open-ended answers as correct, partially correct, or incorrect, with a third researcher for coding discrepancies. RESULTS: Two hundred and four participants completed the survey (55% female; mean age 43; 67% of respondents with a bachelor's degree or higher). Of 14 medical specialties listed on the survey, respondents most accurately identified dermatologists (94%) and cardiologists (93%). Six specialties were understood by less than half of the respondents: neonatologists (48%), pulmonologists (43%), hospitalists (31%), intensivists (29%), internists (21%), and nephrologists (20%). Twelve percent of participants correctly identified medical roles in rank order. Most participants (74%) correctly identified medical students as the least experienced. Senior residents were most often identified as the most experienced (44%), with just 27% of respondents correctly placing the attending there. We conclude that medical professionals should recognize that titles are a common source of misunderstanding among the general public and should describe their role when introducing themselves to minimize confusion.

Accuracy in Patient Understanding of Common Medical Phrases.

Importance: Despite acknowledging that medical jargon should be avoided, health care practitioners frequently use it when communicating with patients. Objective: To characterize the understanding of common medical jargon terms by surveying a cross section of the general public and studying phrases that have established meanings in regular usage but different meanings in a medical context (eg, negative and positive test results). Design, Setting, and Participants: In this cross-sectional study, participants indicated their understanding of phrases that may have different meanings in medicine than in colloquial English via a mix of short answer and multiple choice questions. Several questions included paired phrases to assess for differences in understanding with or without jargon. Volunteers were recruited at the 2021 Minnesota State Fair near St Paul, Minnesota. An electronic survey was given to a volunteer sample of 215 adults (>18 years) who did not work or train to work in the medical field and spoke and read English. Exposures: Completing a written or verbal survey. Main Outcomes and Measures: The main outcome was an accurate understanding of the medical terminology. Free-text responses were coded by 2 researchers for comprehension. Secondary outcomes looked for associations between volunteer demographics and understanding. Results: The 215 respondents (135 [63%] female; mean [SD] age, 42 [17] years) demonstrated a varied ability to interpret medical jargon phrases. For example, most participants (207 [96%]) knew that negative cancer screening results meant they did not have cancer, but fewer participants (143 [79%]) knew that the phrase "your tumor is progressing" was bad news, or that positive lymph nodes meant the cancer had spread (170 [67%]). While most (171 [80%]) recognized that an unremarkable chest radiography was good news, only 44 participants (21%) correctly understood that a clinician saying their radiography was impressive was generally bad news. In each of the paired phrases comparing jargon vs nonjargon approaches, the nonjargon phrase was understood significantly better (P < .001). Conclusions and Relevance: These findings suggest that several common phrases are misunderstood when used in a medical setting, with the interpreted meaning frequently the exact opposite of what is intended.

Say What? Quantifying and Classifying Jargon Use During Inpatient Rounds.

BACKGROUND: Although plain language is recognized as essential for effective communication, research reveals that medical providers regularly use jargon terminology that may be misunderstood by patients. Little is known, however, about the types and frequency of jargon used in the pediatric inpatient setting. We aimed to quantify jargon use by medical team members during inpatient family-centered rounds (FCRs) and to identify the most common categories of jargon used. METHODS: One of 3 trained medical students audited FCRs on a general pediatric service once weekly for 12 weeks, recording and categorizing jargon used with a published classification framework. Jargon usage was classified by category and quantified by using descriptive statistics. Rates were calculated by patient encounter and per minute. Feedback was provided to rounding teams after each observation. RESULTS: During 70 observed FCR patient encounters, there were a total of 443 jargon words or phrases spoken, of which 309 (70%) were not explicitly defined to the patient or family by the health care provider team. The mean number of undefined jargon words or phrases used per patient was 4.3 (±1.7), with a mean of 0.4 (±0.1) uses of undefined jargon per minute. The most common categories of undefined jargon used include technical terminology (eg, bronchiolitis), medical vernacular (eg, cultures), and abbreviations and acronyms (eg, NPO for "nothing by mouth") at 34%, 30%, and 17%, respectively. CONCLUSIONS: Undefined medical jargon was used frequently by health care providers during pediatric FCRs. We found it was feasible to measure provider jargon use and to use a jargon classification scheme to provide real-time, concrete feedback.

Effects of food insecurity on asthma outcomes in the pediatric emergency department.

OBJECTIVES: Food insecurity is associated with a wide variety of adverse health conditions in adults and children, but its relationship to asthma outcomes in children has not been described. The objectives of this study were to assess and characterize the food security status of an inner-city asthmatic population and to determine whether and to what extent household food insecurity is independently associated with negative clinical outcomes in children presenting to a pediatric emergency department (ED) with asthma exacerbations. METHODS: This study is a cross-sectional survey of a convenience sample of families of children presenting to an urban children's hospital ED for asthma exacerbations. Data were gathered through structured chart review and interview, including a published food insecurity questionnaire. RESULTS: A total of 127 families were enrolled, with a median patient age of 6.6 years. Of all families, 81% were black and 10% were white. Of these families, 35% met criteria for household food insecurity. 78% of food-insecure and 46% of food-secure households received food stamps. Of all food-insecure households, 67% reported never using food pantries or free community meals. 36% of food-insecure and 31% of food-secure patients lacked an adequate home supply of asthma medications. The overall admission rate was 37%; no significant difference was found in admission rate or length of stay. CONCLUSIONS: The rate of household food insecurity in families of asthmatic children presenting to an urban ED is high, with relatively low participation in a number of safety net programs. This study failed to demonstrate an association between household food insecurity and negative asthma outcomes.