Provider adherence to a clinical practice guideline for acute asthma in a pediatric emergency department.

UNLABELLED: Critics of the use of clinical practice guidelines (CPGs) in an emergency department (ED) setting believe that they are too cumbersome and time-consuming, but to the best of the authors' knowledge, potential barriers to CPG adherence in the ED have not been prospectively evaluated. OBJECTIVES: To measure provider adherence to an ED CPG based on National Asthma Education and Prevention Program (NAEPP) recommendations, and to determine factors associated with provider nonadherence. METHODS: Prospective, cohort study of children aged 1-18 years with the diagnosis of an acute exacerbation of asthma who were seen in a pediatric ED and requiring admission, as well as a random selection of children discharged to home following pediatric ED care. The following adherence parameters were assessed: at least three nebulized albuterol treatments in the first hour; early steroid administration (after the first nebulizer treatment); clinical assessments using pulse oximetry and peak expiratory flow (PEF) (for children >6 years old); and use of a clinical score to assess acute illness severity (Asthma Severity Score). Nonadherence was defined as any deviation of the above parameters. RESULTS: Between July 1, 1998, and June 30, 1999, 369 patients were studied. Of these, 38% (139) were discharged to home, 38% (140) were admitted to the observation unit, and 24% (90) were admitted to the inpatient unit. Illness severities at initial presentation to the ED were: 24% (86) had mild exacerbations, 59% (212) had moderate exacerbations, and 17% (62) had severe exacerbations. Sixty-eight percent (95% CI = 63% to 73%) of the patients were managed with complete adherence to the CPG. Of the 32% with some form of nonadherence, most (63%) were children older than 6 years; in this group 64% (48/75) were nonadherent due to lack of PEF assessment. When PEF assessment was disregarded, an 83% (95% CI = 79% to 87%) adherence to the CPG was achieved. Other nonadherence factors included: lack of at least three nebulized albuterol treatments provided timely within the first hour (5%); delay in steroid administration (6%); lack of pulse oximeter use (0.5%); and failure to record clinical score to assess severity (1.1%). Patient age, illness severity (acute and chronic), first episode of wheezing, and high ED volume periods (evenings and weekends) did not worsen adherence. CONCLUSIONS: Clinical practice guidelines can be used successfully in the pediatric ED and provide a more efficient management and treatment approach to acute exacerbations of childhood asthma. With a systematic and concise CPG, barriers to adherence in a pediatric ED appear to be minimal, with the exception of using PEF in the routine ED assessment.

Use of out-of-hospital interventions for the pediatric patient in an urban emergency medical services system.

OBJECTIVE: To determine appropriateness of out-of-hospital interventions by emergency medical services (EMS) personnel on children with respiratory illnesses. METHODS: A retrospective, cross-sectional study was performed on a random sample of 304 children transported by an urban EMS system during 1994. Data were abstracted from EMScan (a computerized database of all EMS dispatches) and the EMS narrative records. Appropriate utilization of interventions was determined by comparison with the standard EMS protocol for respiratory complaints in this system. An assessment of whether interventions were inappropriately underutilized or inappropriately overutilized was made. Effect of severity of illness, patient age, transport times, and use of medical command on the use of interventions was evaluated. RESULTS: Two hundred three patients (67%) were classified as having respiratory distress. Overall, 56% of the patients received appropriate interventions, 39% received one or two inappropriate interventions, and 5% received three or more inappropriate interventions. Rates of inappropriate utilization with 95% CI for each intervention were: oxygen 16% (95% CI = 12 to 20), assisted ventilation 2% (95% CI = 0.5 to 4), medication use 9% (95% CI = 6 to 13), vascular access 11% (95% CI = 7 to 14), phlebotomy 9% (95% CI = 6 to 13), and cardiac monitoring 18% (95% CI = 14 to 22). Oxygen and medications were underutilized (p < 0.005), whereas vascular access, cardiac monitoring, and phlebotomy were overutilized (p < 0.005). Online medical command (used in 9% of transports) improved appropriate use of vascular access [OR 8.3 (95% CI = 3 to 25) (p < 0.001)] and cardiac monitoring [OR = 3 (95% CI = 1 to 8) (p < 0.05)]. CONCLUSIONS: Emergency medical services personnel underutilized oxygen and medications and overutilized vascular access, phlebotomy, and cardiac monitoring in children with respiratory illness in this urban setting. Increasing patient age, transport times, and illness severity tend to increase the use of certain interventions, while contact with online medical direction seems to improve appropriate use of interventions.

Severe eclampsia in an adolescent: a case report and review of the literature.

We present this interesting case of an adolescent female with seizures and a history of a fall, who was found to be pregnant and eclamptic, requiring emergent delivery on the day of presentation to a pediatric emergency department. The relevant literature is reviewed.

Factors influencing termination of resuscitative efforts in children: a comparison of pediatric emergency medicine and adult emergency medicine physicians.

OBJECTIVES: To examine factors that influence termination of resuscitative efforts (TORE) and compare pediatric emergency medicine (PEM) and general emergency medicine (GEM) physicians regarding TORE in children. DESIGN: Cross-sectional survey. PARTICIPANTS: All physicians board-certified in PEM as of November 1993 and a random sample of board-certified GEM physicians listed in the 1993 American College of Emergency Physicians directory. INTERVENTIONS: Self-administered questionnaires were mailed to participants who were asked about experience providing pediatric cardiopulmonary resuscitation (CPR) and demographic information. We posed a series of management questions eliciting factors that influence TORE decision-making in single context and case scenario format. Specific emphasis was placed on the influence of time and epinephrine dosing. RESULTS: One hundred and sixty (70%) PEM and 127 (62%) GEM responded. These groups differed significantly in years of experience (PEM 8.2, GEM 11.8), urban practice setting (PEM 84%, GEM 32%) and number of pediatric cardiopulmonary resuscitations per year (PEM 10.6, GEM 4.8), P < 0.001 for all. There were no significant differences between groups regarding features pathognomonic of death. PEM were more likely to consider low blood pH and iatrogenic causes of arrest as factors influencing TORE; GEM were more likely to consider co-morbid conditions (P < 0.05 for all). Medians for time estimates of minimum minutes of pulselessness that influence TORE were: PEM 26 to 30 minutes, GEM 31 to 35 minutes for both prehospital and emergency department settings (P < 0.05 for each). Approximately 20% of all respondents did not place a strict limit on time of pulselessness when determining TORE. No difference was observed between groups regarding maximum doses of epinephrine used prior to TORE. However, fewer GEM (50%) than PEM (75%) utilize "high dose" epinephrine according to current Pediatric Advanced Life Support (PALS) guidelines (P < 0.05). PEM physicians were more than two times more likely to terminate resuscitative efforts if return of spontaneous circulation was not achieved by 25 minutes compared to GEM physicians for both prehospital time of pulselessness [odds ratio 2.1, 95% confidence interval (1.01, 4.5)] and emergency department time of pulselessness [odds ratio 2.2, confidence interval (1.1, 4.6)]. CONCLUSIONS: 1) Several laboratory and clinical factors significantly influence physician's decisions regarding TORE; 2) regardless of setting, time of pulselessness does appear to be an influential factor in determining when to terminate resuscitation in children for most physicians; 3) PEM physicians are more likely to terminate resuscitative efforts than are GEM physicians if return of spontaneous circulation is not achieved by 25 minutes; 4) a significant number of PEM and GEM physicians do not use high dose epinephrine in accordance with current PALS recommendations.

Use of an observation unit by a pediatric emergency department for common pediatric illnesses.

OBJECTIVE: To describe the use of a pediatric observation unit (OU), including relapse rates for common pediatric illnesses, and to assess effectiveness of OU utilization. DESIGN: Retrospective, cohort of all emergency department (ED) visits, OU and inpatient unit (IU) admissions. SETTING: Tertiary care children's hospital. PARTICIPANTS: All children evaluated in the ED and subsequently admitted to either the OU or IU over a 2-year period. MAIN OUTCOME MEASURE: Rates with 95% confidence intervals (CI) for OU use and need for subsequent IU admission from OU, and odds ratios (OR) with 95% CI for use of the OU for specific pediatric disorders. RESULTS: During 10/1/96-9/30/98, there were 44,459 ED visits, 1798 (4.0%) OU admissions, and 3241 (7.3%) inpatient admissions (IA) from the ED. OU mean length of stay was 15.6 +/- 6.1 hours; mean age was 6 +/- 5.3 years with 31% under 2 years of age. Of the total admissions (IU and OU), diagnoses with high OU utilization were: asthma 274/575, 48%; croup 76/125, 61%; enteritis/dehydration 284/470, 60%; poisonings 82/118, 70%; and seizures 80/204, 39%. The likelihood of an OU admission for these illnesses versus IU (adjusted for subsequent need for IU admission) was: asthma OR 1.3 (1.1, 1.5), P < 0.005; croup OR 2.3 (1.6, 3.3), <0.001; enteritis/ dehydration OR 2.8 (2.1, 3.0), P < 0.001; poisonings OR 3.8 (2.5, 5.7), P < 0.001; and seizures OR 0.8 (0.6, 1.2), P = 0.28. For these diagnoses, OU admissions resulting in IU admission occurred for asthma 45/274, 16.4%; croup 7/76, 9.2%; enteritis/ dehydration 13/284, 4.6%; poisonings 3/82, 3.7%; and seizures 15/80, 18.8%, resulting in an overall need for further hospitalization to the IU for these diagnoses of 83/796, 10.4%, (95% CI 8.3, 12.6). CONCLUSION: Admissions to the observation unit comprised over one third of all admissions from a pediatric ED. Certain pediatric illnesses appear to be well suited for admission to the observation unit, with low likelihood of the need for subsequent admission to the inpatient unit. Given the current trends in third-party payer reimbursements for short (<24 hours) admissions, observation unit use provides a more attractive alternative to inpatient admission for many pediatric patients.

Pediatric nonpowder firearm injuries: outcomes in an urban pediatric setting.

BACKGROUND: Approximately 32 000 nonpowder firearm injuries are reported annually with more than 60% occurring in the pediatric population. Case reports of serious and fatal injuries have been described; however, no large inclusive series have been published. We reviewed an 11-year experience of an urban pediatric emergency department to evaluate the circumstances, spectrum of injuries, and outcomes attributable to nonpowder firearms. METHODS: A retrospective, descriptive case series of all children 18 years of age or younger evaluated at an urban children's hospital from January 1983 through December 1994 were eligible for study. Patients were identified using a computerized database, the National Electronic Injury Surveillance System, and the trauma registry in the department of surgery. Medical records were reviewed to collect demographic information, circumstances of injury, anatomic site and type of injury, treatment, and outcomes for nonpowder firearm injuries. RESULTS: One hundred eighty patients were identified, and a complete data set was available for 166 (92%). The mean age was 12 +/- 3.7 years, 24% of children were <10 years old, and 71% of the children were male. Three patients returned with a second nonpowder firearm injury during the study period. Forty-nine percent of injuries were intentional and 44% of all injuries occurred during the summer and early fall months. The most common sites of injury were the extremity/buttocks (39%), head and neck (33%), thorax (13%), and eye (8%). Serious injuries included intracranial hemorrhage, cardiac right ventricle laceration, hyphema, and abdominal visceral injury (liver laceration, pancreatic laceration, intestinal perforation). The majority of wounds required local wound care, and the children (74%) were discharged from the emergency department. Of the patients admitted to the hospital (27%), 45% required operative intervention. There were no deaths. Seven percent (12/166) of patients sustained some functional deficit with 42% (5/12) the result of an ocular injury. CONCLUSION: The majority of nonpowder firearm injuries are minor; however, the potential for serious injury should not be underestimated. Minor injuries can be treated with local wound care and tetanus prophylaxis, and patients can be discharged from the emergency department. Education of parents and children to the potential risks associated with these weapons is essential. Stricter regulations regarding ownership of nonpowder firearms and mandatory safety instruction should be considered.

Observation units: the role of an outpatient extended treatment site in pediatric care.

This article explores the role of extended outpatient treatment in pediatric care, presents important considerations when planning and implementing an outpatient extended treatment site (OETS), discusses operations of a recently opened unit, and examines the research and teaching potential of an OETS.