Improving Care for Children with Bloody Diarrhea at Risk for Hemolytic Uremic Syndrome.

INTRODUCTION: Children with infectious bloody diarrhea are at an increased risk for developing hemolytic uremic syndrome (HUS). Early intervention may improve outcomes. This study evaluated the impact of a clinical pathway designed to identify those at risk for HUS, guide initial management, and provide decision support regarding patient disposition. METHODS: We performed a retrospective cohort study of children 4 months to 19 years of age who presented with the acute onset of bloody diarrhea or other HUS risk factors to the pediatric emergency department (ED) from September 2015 through July 2020. A rapid stool polymerase chain reaction (PCR) test became available in May 2017. The clinical pathway was implemented in January 2018. We used Fisher's exact tests and statistical process control charts to analyze patient- and system-level changes following pathway implementation. RESULTS: Three hundred five patients were included. Postimplementation, stool PCR use increased (78%-91%), hospitalization decreased (49%-30%), and mean total charges decreased ($7715-$6797). There were increases in length of stay (226-288 minutes) and charges ($2651-$3524) for patients discharged from the ED. All changes met rules for special cause variation. There was no change in early IV fluid administration, inpatient length of stay, ED return visits, hospital readmissions, or patients with Shiga toxin-producing Escherichia coli (STEC), acute kidney injury (AKI) or HUS. CONCLUSIONS: For children presenting to the ED with bloody diarrhea, introduction of a rapid stool PCR test and clinical pathway correlated with decreased hospitalizations and overall costs without adverse clinical outcomes.

The Affordable Care Act reduces emergency department use by young adults: evidence from three States.

The Affordable Care Act (ACA) extended eligibility for health insurance for young adults ages 19-25. This extension may have affected how young adults use emergency department (ED) care and other health services. To test the impact of the ACA on how young adults used ED services, we used 2009-11 state administrative records from California, Florida, and New York to compare changes in ED use in young adults ages 19-25 before and after the ACA provision was implemented with changes in the same period for people ages 26-31 (the control group). Following implementation of the ACA provision, the younger group had a decrease of 2.7 ED visits per 1,000 people compared to the older group--a relative change of -2.1 percent. The largest relative decreases were found in women (-3.0 percent) and blacks (-3.4 percent). This relative decrease in ED use implies a total reduction of more than 60,000 visits from young adults ages 19-25 across the three states in 2011. When we compared the probability of ever using the ED before and after implementation of the ACA provision, we found a minimal decrease (-0.4 percent) among the younger group compared to the older group. This suggests that the change in the number of visits was driven by fewer visits among ED users, not by changes in the number of people who ever visited the ED.