Prevalence of Low-Acuity Pediatric Emergency Medical Services Transports to a Pediatric Emergency Department in an Urban Area.

OBJECTIVES: Many patients transported by Emergency Medical Services (EMS) do not have emergent resource needs. Estimates for the proportion of pediatric EMS calls for low-acuity complaints, and thus potential candidates for alternative dispositions, vary widely and are often based on physician judgment. A more accurate reference standard should include patient assessments, interventions, and dispositions. The objective of this study was to describe the prevalence and characteristics of low-acuity pediatric EMS calls in an urban area. METHODS: This is a prospective observational study of children transported by EMS to a tertiary care pediatric emergency department. Patient acuity was defined using a novel composite measure that included physiologic assessments, resources used, and disposition. Bivariable and multivariable logistic regression were conducted to assess for factors associated with low-acuity status. RESULTS: A total of 996 patients were enrolled, of whom 32.9% (95% confidence interval, 30.0-36.0) were low acuity. Most of the sample was Black, non-Hispanic with a mean age of 7 years. When compared with adolescents, children younger than 1 year were more likely to be low acuity (adjusted odds ratio, 3.1 [1.9-5.1]). Patients in a motor vehicle crash were also more likely to be low acuity (adjusted odds ratio, 2.4 [1.2-4.6]). All other variables, including race, insurance status, chief complaint, and dispatch time, were not associated with low-acuity status. CONCLUSIONS: One third of pediatric patients transported to the pediatric emergency department by EMS in this urban area are for low-acuity complaints. Further research is needed to determine low-acuity rates in other jurisdictions and whether EMS providers can accurately identify low-acuity patients to develop alternative EMS disposition programs for children.

Clinician and Caregiver Determinations of Acuity for Children Transported by Emergency Medical Services: A Prospective Observational Study.

STUDY OBJECTIVE: Many Emergency Medical Services (EMS) agencies have developed alternative disposition processes for patients with nonemergency problems, but there is a lack of evidence demonstrating EMS clinicians can accurately determine acuity in pediatric patients. Our study objective was to determine EMS and other stakeholders' ability to identify low acuity pediatric EMS patients. METHODS: We conducted a prospective, observational study of children transported to a pediatric emergency department (ED) by EMS. Acuity was defined using a composite measure that included data from the patient's vital signs and examination, resources used (laboratory results, radiographs, etc), and disposition. For each patient, an EMS clinician, patient caregiver, ED nurse, and ED provider completed a survey as soon as possible after the patient's arrival at the ED. The survey asked respondents 2 questions: to state their level of agreement that a patient was low acuity and could the patient have been managed by various alternative dispositions. For each respondent group, we calculated the sensitivity, specificity, and positive and negative predictive values for low acuity versus the composite measure. RESULTS: From August 2020 through September 2021, we approached 1,015 caregivers, of whom 996 (99.8%) agreed to participate and completed the survey. Survey completion varied between 78.7% and 84.1% for EMS and ED nurses and providers. The mean patient age was 7 years, 62.6% were non-Hispanic Black, and 60% were enrolled in public insurance programs. Of the 996 patient encounters, 33% were determined to be low acuity by the composite measure. The positive predictive value for EMS clinicians when identifying low acuity children was 0.60 (95% confidence intervals [CI], 0.58 to 0.67). The positive predictive value for ED nurses and providers was 0.67 (95% CI, 0.61 to 0.72) and 0.68 (95% CI, 0.63 to 0.74) respectively. The negative predictive value for EMS clinicians when identifying not low acuity children was 0.62 (95% CI, 0.58 to 0.67). The negative predictive value for ED nurses and providers was 0.72 (95% CI, 0.68 to 0.76) and 0.73 (95% CI, 0.70 to 0.77) respectively. Caregivers had the lowest positive predictive value 0.34 (95% CI, 0.30 to 0.40) but the highest negative predictive value 0.82 (95% CI, 0.79 to 0.85). The EMS clinicians, ED nurses and providers were more likely than caregivers to think that a child with a low acuity complaint could have been safely managed by alternative disposition. CONCLUSION: All 4 groups studied had a limited ability to identify which children transported by EMS would have no emergency resource needs, and support for alternative disposition was limited. For children to be included in alternative disposition processes, novel triage tools, training, and oversight will be required to prevent undertriage.

Leaving Without Being Seen From the Pediatric Emergency Department: A New Baseline.

BACKGROUND: Left without being seen (LWBS) rates are an important quality metric for pediatric emergency departments (EDs), with high-acuity LWBS children representing a patient safety risk. Since July 2021, our ED experienced a surge in LWBS after the most stringent COVID-19 quarantine restrictions ended. OBJECTIVE: We assessed changes in LWBS rates and examined associations of system factors and patient characteristics with LWBS. METHODS: We performed a retrospective study in a large, urban pediatric ED for all arriving patients, comparing the following three time-periods: before COVID-19 (PRE, January 2018-February 2020), during early COVID-19 (COVID, March 2020-June 2021), and after the emergence of COVID-19 variants and re-emergence of seasonal viruses (POST, July 2021-December 2021). We compared descriptive statistics of daily LWBS rates, patient demographic characteristics, and system characteristics. Negative binomial (system factors) and logistic regression (patient characteristics) models were developed to evaluate the associations between system factors and LWBS, and patient characteristics and LWBS, respectively. RESULTS: Mean daily LWBS rates changed from 1.8% PRE to 1.4% COVID to 10.7% during POST. Rates increased across every patient demographic and triage level during POST, despite a decrease in daily ED volume compared with PRE. LWBS rates were significantly associated with patients with an Emergency Severity Index score of 2, mean ED census, and staff productivity within multiple periods. Patient characteristics associated with LWBS included lower assigned triage levels and arrival between 8 pm and 4 am. CONCLUSIONS: LWBS rates have shown a large and sustained increase since July 2021, even for high-acuity patients. We identified system factors that may provide opportunities to reduce LWBS. Further work should develop strategies to prevent LWBS in at-risk patients.

Relationship Between Food Insecurity and Neighborhood Child Opportunity Index.

OBJECTIVES: To evaluate the association between the Child Opportunity Index (COI) and food insecurity. STUDY DESIGN: This was a secondary analysis of a comprehensive screening instrument for social determinants of health and behavioral health risks. It was administered in 2 urban pediatric emergency departments to adolescents aged 13-21 years and caregivers of children aged 0-17 years. Food insecurity was assessed using the 2-item Hunger Vital Sign. Residential addresses were geocoded and linked with COI data. Bivariable and multivariable logistic regression models were developed to measure the relationship between COI and food insecurity. RESULTS: Of the 954 participants (384 adolescents, 570 caregivers) who underwent screening, 15.7% identified food insecurity (14.3% of adolescent and 16.7% of caregiver participants). The majority of participants were non-Hispanic Black (overall, 62.3%; food secure, 60.9%; food insecure, 72.0%), were publicly insured (overall, 56.6%; food secure, 53.1%; food insecure, 73.3%), and lived in neighborhoods of low/very low opportunity (overall, 76.9%; food secure, 74.7%; food insecure, 88.3%). In adjusted analyses, participants living in neighborhoods of low/very low child opportunity had 3-fold greater odds of being food insecure compared with children living in neighborhoods of high child opportunity (aOR, 3.0; 95% CI, 1.4-6.3). CONCLUSION: We demonstrate that food insecurity is associated with lower neighborhood opportunity. Our results could inform future screening initiatives and support the development of novel, place-based interventions to tackle the complex issue of food insecurity.

Creation and validation of a citywide pediatric asthma registry for the District of Columbia.

OBJECTIVE: To create and validate a citywide pediatric Asthma Registry to improve the care and outcomes of children and adolescents in Washington, DC through data-driven quality improvement (QI). METHODS: All available electronic health record data from inpatient and outpatient domains of Children's National Hospital were aggregated from an existing enterprise data warehouse. Inclusion criteria included asthma relevant ICD-10 codes over the prior 24 months. Available Asthma Registry measures include patient demographics, ambulatory visits, hospital admissions, persistent asthma diagnoses, and prescription of controller medications. Data capture was validated using US Census data and current asthma prevalence estimate of the Behavioral Risk Factor Surveillance System (BRFSS). RESULTS: The registry identified 15,991 DC children and adolescents with asthma aged 0-17 years, inclusive, at the end of 2020. This was 14.2% higher than the estimate of 14,001 children derived from BRFSS. Characteristics of those in the registry included: mean age of 9.5 (1.4) years, 57.9% male, 72.3% Black, and 66.7% publicly insured. Over the prior 24 months, 30.3% had ≥1 emergency department visit, and 10.5% had ≥1 hospital admission. Controller medications were prescribed for 59.6% of children with persistent asthma. Rates varied by sampled primary care practice sites. CONCLUSIONS: A population-level pediatric asthma registry captures more children and adolescents with asthma in DC then a BRFSS-derived estimate, and provides city-wide measures of asthma-related utilization. The registry allows for stratification by primary care practice locations and asthma characteristics, supporting the design, implementation, and evaluation of QI projects at the practice, health system, and population levels.Supplemental data for this article can be accessed at publisher's website.

Variability in advanced imaging of pediatric neck infections in US emergency departments.

OBJECTIVES: To describe the use of computed tomography (CT) and ultrasound (US) imaging for the evaluation of neck infections in pediatric patients in United States emergency departments (EDs). METHODS: This is a cross-sectional analysis, using the National Emergency Department Sample database, of pediatric patients evaluated for common neck infections between 2012 and 2018. We used bivariable analysis to assess for differences in US and CT use by ED type. We performed multivariable logistic regression to adjust for potential confounding factors including patient characteristics (sex, age, insurance status, discharge diagnosis) and ED characteristics (metropolitan statistical area, pediatric center). Results are reported as odds ratios and adjusted odds ratios with 95% confidence intervals. RESULTS: There were 19,363 ED visits for pediatric neck infections in the database over the study period, representing 84,439 national visits. Of those imaged, 80.8% were imaged with CT and 19.2% were imaged with US. Pediatric patients evaluated in general EDs as compared to pediatric EDs (aOR 5.32, 95% CI 3.06, 9.24) and patients with a diagnosis of peritonsillar abscess (aOR 2.11, 95% CI 1.34, 3.33) and retropharyngeal abscess (aOR 6.12, 95% CI 2.14, 17.53) were more likely to be imaged with CT scan. CONCLUSIONS: Children with neck infections evaluated in general EDs are significantly more likely to undergo CT scans when compared to those evaluated in pediatric EDs. To reduce exposure to radiation in children, we propose the dissemination of US-first protocols in general EDs for the evaluation of pediatric neck infections.

Variations in Safe Sleep Practices and Beliefs: Knowledge is not Enough.

OBJECTIVES: Sleep-related infant deaths in the District of Columbia (DC) varies, with rates in certain geographical areas three times higher than DC and seven times higher than the national average. We sought to understand differences in infant sleep knowledge, beliefs, and practices between families in high-risk infant mortality and low-risk infant mortality areas in DC. METHODS: Caregivers of infants presenting to the emergency department were surveyed. The associations between location and safe sleep knowledge, beliefs, and practices were analyzed. RESULTS: Two hundred and eighty-four caregivers were surveyed; 105 (37%) were from the high-risk infant mortality area. The majority (68%) of caregivers reported placing their infant to sleep on their backs, sleeping in a crib, bassinet, or pack and play (72%), and were familiar with the phrase "safe sleep" (72%). Caregivers from the high-risk infant mortality area were more likely to report that their infants sleep in homes other than their own (aOR 1.53; 95% CI 1.23, 2.81) and other people took care of their infants while sleeping (aOR 1.76; 95% CI 1.17, 3.19), adjusting for race/ethnicity, education, marital status, and help with childcare. No differences in safe sleep knowledge, beliefs, and practices were present. CONCLUSIONS FOR PRACTICE: Infants from the high-risk infant mortality area were more likely to sleep in homes other than their own and have other caretakers while sleeping. Lack of differences in caregiver awareness of safe sleep recommendation or practices suggests effective safe sleep messaging. Outreach to other caregivers and study of unmet barriers is needed.

Frequency of Opioid Prescription Filling After Discharge from the Pediatric Emergency Department.

BACKGROUND: Little is known about prescription filling of pain medicine for children. In adult populations, race and insurance type are associated with differences in opioid prescription fill rate. We hypothesize that known disparities in pain management for children are exacerbated by the differential rates of opioid prescription filling between patients based on age and race. OBJECTIVE: To determine if there are demographic or clinical factors associated with differences in opioid prescription fill rates after discharge from the pediatric emergency department (ED). METHODS: This was a retrospective cross-sectional study of all patients younger than 19 years discharged with an opioid prescription from either of two pediatric EDs in 2018. We performed multivariable logistic regression to measure associations between prescription filling and demographic and clinical factors. RESULTS: There were 287 patient visits in which opioids were prescribed. Forty percent of prescriptions were filled. The majority of patients were male (53%), black (69%), and had public insurance (55%). There were no significant associations between prescription filling and age, insurance status, or race/ethnicity. Patients with sickle cell disease were more likely to fill prescriptions (odds ratio 3.87, 95% confidence interval 2.33-6.43) and patients without an identified primary care provider were less likely to fill prescriptions (odds ratio 0.16, 95% confidence interval 0.03-0.84). CONCLUSION: Less than half of opioid prescriptions prescribed at discharge from a pediatric emergency department are filled. Patient age, insurance status, and race/ethnicity are not associated with opioid prescription filling. Patients with sickle cell disease and those with a primary care provider are more likely to fill their opioid prescriptions.

Determining Intentionality of Pediatric Firearm Injuries by International Classification of Disease Code.

OBJECTIVE: Firearm injuries are a leading cause of serious injury and death in childhood. The accuracy of International Classification of Disease (ICD) codes to assign intent is unclear. The objective of this study was to assess the validity of documented ICD codes for firearm injury intent compared with chart review. METHODS: We performed a retrospective cohort study of children (<= 18 years) presenting to a tertiary care level 1 pediatric trauma center with firearm injuries between 2006 and 2017. We compared agreement between ICD codes and intent of injury determined by medical record review using Cohen κ. Intent for medical record review was assigned via the injury spectrum of intentionality (suicide attempt, accidental firing, mistaken target, firearm assault and unknown). For comparison with ICD codes, all medical record review cases marked as mistaken target were classified as accidental. A sensitivity analysis was then performed, coding all mistaken targets as assault. RESULTS: There were 122 cases identified over the study period. The most common intent by ICD code was assault (n = 80, 65.6%). Medical record review categorized most injuries as mistaken targets. When mistaken target was categorized as accidental, most firearm injuries were coded as accidental (n = 89, 72.9%) Similar results were seen when mistaken target was categorized as assault, most injuries were categorized as assault (n = 79, 79.5%) Cohen κ was 0.15 when mistaken targets were categorized as accident and 0.30 when categorized as assault. CONCLUSIONS: The ICD codes do not fully describe the intent of firearm injury. Revising ICD codes to account for mistaken targets could help to improve the validity of ICD codes for intent.

Experiencing Bullying Is Associated With Firearm Access, Weapon Carriage, Depression, Marijuana Use, and Justice Involvement in Adolescents.

OBJECTIVES: The aims of this study were to assess whether bullying experience among youths is associated with firearm access and to evaluate assault perpetration risk factors between bullied and nonbullied adolescents. METHODS: This was a secondary analysis of a cross-sectional survey designed to measure self-reported social determinants of health and behavioral health risks among adolescents (13-21 years) in a pediatric emergency department between July 2017 and August 2019. Participants were included in this subanalysis if they responded to a survey item that assessed bullying. Multivariable logistic regression was used to measure the association of firearm access, weapon carriage, and assault perpetration factors (violence, mental health, substance abuse, and justice involvement) with bullying after adjustment for sex, race/ethnicity, and insurance status. RESULTS: Of the 369 participants meeting inclusion criteria, 147 adolescents (40.5%) reported experiencing bullying. Bullied teenagers had higher odds of a gun in the home (adjusted odds ratio [aOR], 3.0; 95% confidence interval [CI], 1.2-7.8]), weapon carriage (aOR, 5.6; 95% CI, 1.6-18.8), witnessing an assault (aOR, 3.0; 95% CI, 1.6-5.6), negative experience with law enforcement (aOR, 4.5; 95% CI, 2.2-9.2), mental health diagnosis (aOR, 3.9; 95% CI, 2.3-6.7), and marijuana use (aOR, 2.7; 95% CI, 1.1-7.0]). CONCLUSIONS: More than 1 in 3 adolescents presenting to the emergency department report having ever experienced bullying. Bullied teenagers have a higher likelihood of firearm access, weapon carriage, and violent injury perpetration risk factors compared with nonbullied youths. Further studies are needed to understand the relationship between bullying and assault perpetration.

Racial and Ethnic Disparities in Pediatric Mental Health-Related Emergency Department Visits.

OBJECTIVES: To test the hypotheses that (1) rates of mental health-related concerns presenting to pediatric emergency departments (ED) have increased (2) rates are increasing more in minority than nonminority youth. METHODS: We performed a 5-year retrospective cohort study of youth with mental health-related ED visits using the Pediatric Health Information System. We calculated rates of mental health-related visits, in aggregate and by race/ethnicity. The Poisson model was used to generate incidence rate ratios of unique mental health-related visits each year using census data as the population denominator. RESULTS: There were 242,036 mental health-related visits that met the inclusion criteria, representing 160,656 unique patients. Approximately 7% of unique patients had 3 or more mental health-related visits, differing by race/ethnicity (8.75% non-Hispanic [NH]-Black vs 7.01% NH-White; adjusted odds ratio 1.14 [1.03, 1.26]). Overall, there were 42.8 mental health-related ED visits per 100,000 US children. The NH-Black children had higher rates of visits per 100,000 children compared with NH-Whites (66.1 vs 41.5; adjusted relative risk, 1.54 [1.50-1.59]). Mental health-related visits increased from 2012 to 2016 (33.31 [32.92-33.70] to 49.94 [49.46-50.41]). Every racial/ethnic group experienced an increase in rate of presentation over the study period; Hispanics experienced a significantly larger increase compared with NH-White children (P < 0.05). CONCLUSIONS: Mental health-related ED visits among children are increasing overall, disproportionally affecting minority children. The NH-Black children have the highest visit rates, and rates among Hispanics are increasing at a significantly higher rate when compared with NH-Whites. These results indicate need for increased capacity of EDs to manage mental health-related complaints, especially among minority populations.

Adequacy of Emergency Department Documentation of Child Restraint Use After a Motor Vehicle Crash.

OBJECTIVES: There are limited data on how often providers collect and document adequate restraint information in children seen in the emergency department (ED) after motor vehicle crashes (MVCs). The objectives of this study are to determine (1) how often adequate child restraint information to determine age-appropriate use is documented after MVC; (2) the frequency of incorrect use of the child restraint when adequate details are documented; and (3) for those discharged from the ED with identified incorrect use, the frequency of provision of information on child passenger safety (CPS). METHODS: Retrospective chart review of visits of children younger than 13 years with an International Classification of Diseases, Tenth Revision code for MVC to an urban, academic, level 1 pediatric trauma center, from October 2015 to September 2018. Adequate documentation of child restraint use was defined as identification of location of the child in the car (front vs rear row), type of restraint used, and forward or rear facing for children 24 months or younger. RESULTS: A total of 165 visits qualified for inclusion. There was adequate documentation in 46% of visits. Of those, incorrect child restraint use was identified in 49%. Of discharged patients with incorrect use, 10% had documentation of provision of CPS information. CONCLUSIONS: Adequate details to determine proper age-appropriate restraint use are documented in only half of ED visits for MVC. Very few are given CPS instructions on discharge, even when incorrect use has been identified. Identification of incorrect restraint use in the ED is an opportunity for a teachable moment that is being underused.

Results of Testing Children for Severe Acute Respiratory Syndrome Coronavirus-2 Through a Community-based Testing Site.

OBJECTIVE: To describe the demographics, clinical features, and test results of children referred from their primary provider for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in the community setting. STUDY DESIGN: Retrospective cross-sectional study of children ≤22 years of age who were tested for SARS-CoV-2 at a community-based specimen collection site in Washington, DC, affiliated with a large children's hospital between March 21 and May 16, 2020. RESULTS: Of the 1445 patients tested at the specimen collection site for SARS-CoV-2 virus, 408 (28.2%) had a positive polymerase chain reaction test. The daily positivity rate increased over the study period, from 5.4% during the first week to a peak of 47.4% (Ptrend < .001). Patients with fever (aOR, 1.7; 95% CI, 1.3-2.3) or cough (aOR, 1.4; 95% CI, 1.1-1.9) and those with known contact with someone with confirmed SARS-CoV-2 infection (aOR, 1.6; 95% CI, 1.0-2.4.) were more likely have a positive test, but these features were not highly discriminating. CONCLUSIONS: In this cohort of mildly symptomatic or well children and adolescents referred to a community drive-through/walk-up SARS-CoV-2 testing site because of risk of exposure or clinical illness, 1 in 4 patients had a positive test. Children and young adults represent a considerable burden of SARS-CoV-2 infection. Assessment of their role in transmission is essential to implementing appropriate control measures.

United States trends in healthcare charges for pediatric firearm injuries.

BACKGROUND: From 2009 to 2016, >21,000 children died and an estimated 118,000 suffered non-fatal injuries from firearms in the United States. Limited data is available on resource utilization by injury intent. We use hospital charges as a proxy for resource use and sought to: 1) estimate mean charges for initial ED and inpatient care for acute firearm injuries among children in the U.S.; 2) compare differences in charges by firearm injury intent among children; and 3) evaluate trends in charges for pediatric firearm injuries over time, including within intent subgroups. METHODS: In this repeated cross-sectional analysis of the 2009-2016 Nationwide Emergency Department Sample, we identified firearm injury cases among children aged ≤19 years using ICD-9-CM and ICD-10-CM external cause of injury codes (e-codes). Injury intent was categorized using e-codes as unintentional, assault-related, self-inflicted, or undetermined. Linear regressions utilizing survey weighting were used to examine associations between injury intent and healthcare charges, and to evaluate trends in mean charges over time. RESULTS: Among 21,951 unweighted cases representing 102,072 pediatric firearm-related injuries, mean age was 16.6 years, and a majority were male (88.2%) and publicly insured (51.5%). Injuries were 53.9% assault-related, 37.7% unintentional, 1.8% self-inflicted, and 6.7% undetermined. Self-inflicted injuries had higher mean charges ($98,988) than assault-related ($52,496) and unintentional ($28,618) injuries (p < 0.001). Self-inflicted injuries remained associated with higher mean charges relative to unintentional injuries, after adjusting for patient demographics, hospital characteristics, and injury severity (p = 0.015). Mean charges for assault-related injuries also remained significantly higher than charges for unintentional injuries in multivariable models (p < 0.001). After adjusting for inflation, mean charges for pediatric firearm-related injuries increased over time (p-trend = 0.018) and were 23.1% higher in 2016 versus 2009. Mean charges increased over time among unintentional injuries (p-trend = 0.002), but not among cases with assault-related or self-inflicted injuries. CONCLUSIONS: Self-inflicted and assault-related firearm injuries are associated with higher mean healthcare charges than unintentional firearm injuries among children. Mean charges for pediatric firearm injuries have also increased over time. These findings can help guide prevention interventions aimed at reducing the substantial burden of firearm injuries among children.

Trends in Pediatric Poisoning-Related Emergency Department Visits: 2001-2011.

OBJECTIVES: We sought to understand the burden of pediatric poisonings on the health care system by characterizing poisoning-related emergency department (ED) visits among children on a national level. METHODS: This was a repeated cross-sectional analysis of the National Hospital Ambulatory Medical Care Survey from 2001 to 2011 of children 21 years or younger who presented to an ED. We measured annual rates of visits, trends over time, and patient and visit characteristics associated with poisoning-related ED visits using multivariable logistic regression. We also compared accidental to intentional poisonings. RESULTS: There were an estimated 713,345 ED visits per year for poisoning in children, and intentional poisoning-related visits increased over the study period (P trend < 0.001). Compared with all other ED visits, poisoning-related ED visits were more common among males (adjusted odds ratio [aOR], 1.44; 95% confidence interval [CI], 1.26-1.64) and uninsured patients (aOR, 1.26; 95% CI, 1.05-1.51). Poisoned children were more likely to arrive by ambulance (aOR, 3.38; 95% CI, 2.85-4.01) and be admitted (aOR, 1.35; 95% CI, 1.12-1.61). Compared with accidental poisonings, intentional poisonings were more common as age increased (aOR, 1.16; 95% CI, 1.13-1.92) and in children of non-Hispanic black race/ethnicity (aOR, 1.81; 95% CI, 1.12-2.93) and more likely to be associated with ambulance arrival (aOR, 1.49; 95% CI, 1.07-2.08) and hospital admission (aOR, 1.76; 95% CI, 1.25-2.48). CONCLUSIONS: Poisoning-related ED visits among children have remained stable, with significant increase in intentional ingestions from 2001 to 2011. Poisoned children, and particularly those with intentional poisonings, require more health care resources than children with other health concerns. More study is needed on circumstances leading to pediatric poisonings, so that preventive efforts can be targeted appropriately.

Attitudes Toward Electronic Sexual Health Assessments Among Adolescents in the Emergency Department.

OBJECTIVES: Adolescents account for nearly half of all newly diagnosed sexually transmitted infection (STI) cases in the United States and frequently access health care via emergency departments (EDs). However, there are many barriers to ED-based STI screening. Electronic sexual health assessments may overcome some of these ED-specific barriers. Thus, the objective of this study was to assess adolescent attitudes toward electronic sexual health assessments to guide STI screening in the ED. METHODS: This was a secondary analysis of data from 2 cross-sectional studies evaluating acceptability of electronic sexual health assessments in the pediatric ED. Study participants completed an electronic questionnaire that elicited sexual behavior information and attitudes toward electronic sexual health assessments. We interrogated the electronic health record to determine if sexual histories were documented, and if so, we assessed patient preference for mode of assessment. We performed multivariable logistic regression to identify demographic factors associated with acceptance of electronic sexual health assessments. RESULTS: Of the 1159 adolescents surveyed, 935 (80.7%; 95% confidence interval, 78.3-82.9) found electronic assessments an acceptable method by which to provide sexual health information. The majority (n = 874 [75.4%]; 72.8-77.9) reported a preference for electronic assessments over other modes of assessment. Acceptance of electronic assessments was associated with STI-related chief complaint (adjusted odds ratio, 1.7; 1.0-2.7) and private insurance (adjusted odds ratio, 1.8; 1.2-2.7). CONCLUSIONS: Electronic sexual health assessments are acceptable to adolescents and are an efficient alternative to face-to-face sexual health assessments. Future studies should focus on how best to integrate electronic assessments into the ED workflow.

Regional Differences in Pediatric Firearm-Related Emergency Department Visits and the Association With Firearm Legislation.

OBJECTIVE: The objective of this study was to describe regional and temporal trends in pediatric firearm-related emergency department (ED) visits and investigate association with regional firearm legislation. METHODS: We conducted a cross-sectional analysis using the Nationwide Emergency Department Sample from 2009 to 2013 for children aged 21 years or younger. We calculated national estimates of firearm-related visits using annual census data and measured trends. We used state-level gun law scores to derive regional scores to measure strictness of firearm legislation. We used multivariable logistic and linear regression to measure regional differences in visits and their association with regional gun law scores, respectively. RESULTS: There were 111,839 (95% confidence interval, 101,248-122,431) ED visits for pediatric firearm-related injuries. Rates of visits varied by region, with the lowest rate in the Northeast and highest rate in the South (40.0 [34-45]; 70.8 [63.7-76.9] per 100,000 ED visits, respectively). Compared with the Northeast, odds of firearm-related ED visits were higher in the Midwest (adjusted odds ratio [aOR], 1.8; 1.4-2.3), West (aOR, 2.5; 2.0-3.2), and South (aOR, 1.9; 1.5-2.4). Firearm-related visits remained consistent over time. A higher (stricter) regional median Brady gun law score was associated with a lower rate of firearm-related visits (ß = -0.8; R2 = 0.9; P = 0.03). CONCLUSIONS: Rates of pediatric firearm-related ED visits vary by region. Stricter regional gun laws were associated with lower rates of ED visits for pediatric firearm-related injuries. Further study of the social and cultural regional differences in gun ownership and the role of legislation in the prevention of pediatric firearm-related morbidity and mortality is warranted.

Adolescent Attitudes Toward Sexually Transmitted Infection Screening in the Emergency Department.

OBJECTIVES: Adolescents who seek care in emergency departments (EDs) are often at high risk for sexually transmitted infections (STIs). The objective of this study was to assess adolescent attitudes toward ED-based STI screening. METHODS: We conducted a secondary analysis of a cross-sectional study that evaluated STI screening acceptability and prevalence when STI testing was universally offered to asymptomatic adolescents presenting to the ED for care. Adolescents 14 to 21 years old completed a computerized survey and answered questions regarding attitudes toward ED-based STI screening and sexual behavior. We performed multivariable logistic regression to compare differences in attitudes toward ED-based STI screening among patients who agreed versus declined STI testing. RESULTS: Of 553 adolescents, 326 (59.0%) agreed to be tested for STIs. Most (72.1%) believed the ED was an appropriate place for STI screening. Patients who agreed to be tested for STIs were more likely to positively endorse ED-based STI screening than those who declined STI testing [77.0% vs 64.8%; adjusted odds ratios, 1.6; 95% confidence interval (CI), 1.1-2.4]. Most (82.6%) patients stated they would feel comfortable getting tested for STIs in the ED. There was no difference in the comfort level of ED-based STI testing between those who agreed and declined STI testing (83.5% vs 81.4%; adjusted odds ratios, 1.1; 95% CI, 0.7-1.8). CONCLUSION: Our results suggest that adolescents view the ED as an acceptable location for STI screening. Therefore, the ED may serve a role in increasing the accessibility of STI detection and prevention resources for adolescents.

Postpartum Depression Screening and Referral in a Pediatric Emergency Department.

OBJECTIVES: The aim of this study was to determine the (1) proportion of screened postpartum depression (PPD)-positive mothers, (2) associated risk factors, and (3) impact of PPD screening in a pediatric emergency department (PED). STUDY DESIGN: We performed a pilot cohort study using a convenience sample of mothers (n = 209, all ages) of infant patients 6 months or younger presenting to a PED. Mothers completed a computerized survey that included the Edinburgh Postnatal Depression Scale. We assessed frequency of positive screens and performed multivariable logistic regression to identify associated risk factors. We assessed maternal attitudes toward screening at enrollment and 1-month follow-up with positive-screen mothers. Differences in ED utilization were measured. RESULTS: Fifty-seven of 209 mothers (27%; 95% confidence interval [CI], 21%-33%) screened positive for PPD, with 14 (7%) reporting suicidal thoughts. Forty-seven percent (97/209) had never previously been screened, including 58% (33/57) of PPD screen-positive mothers. Current unemployment status (adjusted odds ratio [aOR], 2.76; 95% CI, 1.25-6.13) and first-time motherhood (aOR, 3.92; 95% CI, 1.72-8.91) were associated with a positive screen. At 1-month follow-up, mothers (35/37) reported PED-based PPD screening was important. After adjustment for sociodemographic factors, PPD screen-positive mothers had increased PED utilization (aOR, 1.29; 95% CI, 1.03-1.61). CONCLUSIONS: Approximately 1 in 4 mothers screened positive for PPD in a PED, with almost 1 in 10 reporting suicidal thoughts. The majority of PPD screen-positive mothers had not been screened previously. Our study helps to inform future efforts for interventions to support mothers of young infants who use the PED for care.

Adolescent Sexual Behavior and Emergency Department Use.

OBJECTIVES: The objective of this study was to determine whether adolescents in emergency departments (EDs) who report engaging in high-risk sexual behaviors are less likely to identify a primary care provider (PCP) and more likely to access the ED than their sexually inexperienced peers. METHODS: This was a secondary analysis of adolescents presenting to a pediatric ED with non-sexually transmitted infection (STI)-related complaints who completed surveys to assess sexual behavior risk and health care access. We measured differences in self-reported PCP identification, preferential use of the ED, and number of ED visits over a 12-month period by sexual experience. Secondary outcomes included clinician documented sexual histories and STI testing. RESULTS: Of 758 patients meeting inclusion criteria, 341 (44.9%) were sexually experienced, and of those, 129 (37.8%) reported engaging in high-risk behavior. Participants disclosing high-risk behavior were less likely to identify a PCP (adjusted odds ratio, 0.5; 95% confidence interval [CI], 0.3-0.9), more likely to prefer the ED for acute care issues (adjusted odds ratio, 1.6; 95% CI, 1.0-2.6), and had a higher rate of ED visits (adjusted relative risk, 1.2; 95% CI, 1.0-1.3) compared with sexually inexperienced peers. Among patients disclosing high-risk behavior, 10.9% had clinician-documented sexual histories and 2.6% underwent STI testing. CONCLUSION: Adolescents who reported engaging in high-risk sexual behaviors were less likely to identify a PCP, as well as more likely to prefer ED-based care and make more ED visits. However, ED clinicians infrequently obtained sexual histories and performed STI testing in asymptomatic youth, thereby missing opportunities to screen high-risk adolescents who may lack access to preventive care.