Experience with the use of propofol for radiologic imaging in infants younger than 6 months of age.

BACKGROUND: There is an increased risk associated with procedural sedation of infants younger than 6 months of age. The use of propofol for radiologic imaging of this age group is not well studied. OBJECTIVE: We hypothesize that adverse events are higher in the infant population receiving propofol for radiologic imaging. MATERIALS AND METHODS: A retrospective chart review was undertaken of 304 infants younger than 6 months old who received propofol for procedural sedation from October 2012 to February 2015. Patient demographics, propofol dosing, sedation-related adverse events and interventions were collected. Serious adverse events were defined as laryngospasm, aspiration, the need for admission, cardiac arrest or death. RESULTS: Procedural sedation for radiologic imaging was successful in 301/304 (99%) of infants using propofol. Of these 304 patients, 130 (42.8%) patients were female, and 240 of the 304 (79%) were between 3 and 6 months of age. The majority of patients (172/304 [56.6%]) were American Society of Anesthesiologists-Physical Status Class II. There were 57 sedation-related, minor adverse events in 39 out of 304 (12.8%) patients. Thirteen of the 304 (4.3%) patients had 14 serious adverse events, with airway obstruction the most common. Eighty interventions were required in 56/304 (18.4%) patients. The most common interventions were continuous positive airway pressure (CPAP) in 25/304 patients (8.2%) and jaw thrust in 15/304 (4.9%). The median induction propofol dose was 4.7 mg/kg. A need for an increase in the propofol infusion rate during the procedure was noted in 162/304 (53.3%) infants. No significant predictors of sedation-related adverse events were detected. CONCLUSION: Propofol can be used for radiologic imaging of infants younger than 6 months of age with a high success rate. Practitioners should be mindful of significantly higher dosing requirements and a higher incidence of airway events, which can be easily identified and managed by a team of experienced sedation providers.

Syncope in the Pediatric Emergency Department - Can We Predict Cardiac Disease Based on History Alone?

BACKGROUND: The American Heart Association recommends a "meticulous history" when evaluating patients with an initial episode of syncope. However, little is known about which historical features are most helpful in identifying children with undiagnosed cardiac syncope. OBJECTIVES: Our objectives were 1) to describe the cardiac disease burden in Emergency Department (ED) syncope presentations, and 2) to identify which historical features are associated with a cardiac diagnosis. METHODS: Using syncope presentations in our ED between May 1, 2009 and February 28, 2013, we 1) performed a cross-sectional study describing the burden of cardiac syncope, and 2) determined the sensitivity and specificity of four historical features identifying cardiac syncope. RESULTS: Of 3445 patients, 44.5% were male presenting at 11.5 ± 4.5 years of age. Of patients with a cardiac diagnosis (68, ~2%), only 3 (0.09%) were noted to have a previously undiagnosed cardiac cause of syncope: 2 with supraventricular tachycardia and 1 with myocarditis. Among the three cases and 100 randomly selected controls, the respective sensitivity and specificity of the historical features were 67% and 100% for syncope with exercise, 100% and 98% for syncope preceded by palpitations, and 67% and 70% for syncope without prodrome. The presence of at least two features yielded a sensitivity of 100% and specificity of 100%. CONCLUSIONS: Our study, which represents the largest published series of pediatric syncope presenting to the ED, confirms that newly diagnosed cardiac causes of syncope are rare. Using a few specific historical features on initial interview can help guide further work-up more precisely.

How well do General EMS 911 dispatch protocols predict ED resource utilization for pediatric patients?

INTRODUCTION: The use of Emergency Medical Services (EMS) for low-acuity pediatric problems is well documented. Attempts have been made to curb potentially unnecessary transports, including using EMS dispatch protocols, shown to predict acuity and needs of adults. However, there are limited data about this in children. The primary objective of this study is to determine the pediatric emergency department (PED) resource utilization (surrogate of acuity level) for pediatric patients categorized as "low-acuity" by initial EMS protocols. METHODS: Records of all pediatric patients classified as "low acuity" and transported to a PED in winter and summer of 2010 were reviewed. Details of the PED visit were recorded. Patients were categorized and compared based on chief complaint group. Resource utilization was defined as requiring any prescription medications, labs, procedures, consults, admission or transfer. "Under-triage" was defined as a "low-acuity" EMS transport subsequently requiring emergent interventions. RESULTS: Of the 876 eligible cases, 801 were included; 392/801 had no resource utilization while 409 of 801 had resource utilization. Most (737/801) were discharged to home; however, 64/801 were admitted, including 1 of 801 requiring emergent intervention (under-triage rate 0.12%). Gastroenterology and trauma groups had a significant increase in resource utilization, while infectious disease and ear-nose-throat groups had decreased resource utilization. DISCUSSION: While this EMS system did not well predict overall resource utilization, it safely identified most low-acuity patients, with a low under-triage rate. This study identifies subgroups of patients that could be managed without emergent transport and can be used to further refine current protocols or establish secondary triage systems.

Adult patients in the pediatric emergency department: presentation and disposition.

BACKGROUND: Pediatric emergency departments (PEDs) are intended to care for acutely ill and injured children. Adult patients sometimes present to these facilities as well. Some of these are young adults still under the care of pediatric specialists, but older adults and those not under the care of specialists may seek care and may challenge pediatric care providers. Understanding the spectrum of adult illness encountered in the PED may help ensure optimum care for this patient population. OBJECTIVE: This study aimed to describe the presentations of adult patients in 2 high-volume PEDs of a pediatric health care system. METHODS: This is a retrospective review of electronic medical record to identify all visits for patients 21 years or older between 2008 and 2010. Patient demographics, reason for visit, diagnosis, and treatment details were identified. RESULTS: The combined PEDs recorded 417,799 total visits with 1097 patients 21 years or older; 188 of these were still followed by pediatric specialists. For the 907 remaining, the mean age was 36.5.years (range, 21-88 years); 73% were female. Fifty-one percent of the patients were triaged into the highest acuity levels. Fifty-seven percent of the patients were transferred to adult facilities for definitive care. There were no deaths among these patients at either PED, but 2 patients did require intubation and 1 received a period of chest compressions. Reason for presenting to the PED included on-site visitor (45%), mistakenly presented to children's hospital (34%), and hospital employee (21%). The most common presenting complaints were neurologic conditions, trauma/acute injuries, and chest pain. CONCLUSIONS: Adult patients in PEDs are rare but have relatively high acuity and often require transfer. Pediatric emergency department clinicians should have adequate, ongoing training to capably assess and stabilize adult patients across a spectrum of illness presentation.

The use of ondansetron for nausea and vomiting after head injury and its effect on return rates from the pediatric ED.

BACKGROUND: The use of ondansetron in children with vomiting after a head injury has not been well studied. Concern about masking serious injury is a potential barrier to its use. OBJECTIVE: The aim of this study was to evaluate the use of ondansetron in children with head injury and symptoms of vomiting in the pediatric emergency department (PED) and its effect on return rates and masking of more serious injuries. DESIGN/METHODS: Visits to 2 PEDs from 2003 to 2010 with a diagnosis of head injury were evaluated retrospectively. Patients discharged home after a head computed tomography (CT) are the primary cohort for the study. A logistic regression model was used to analyze ondansetron's effects on the likelihood of return to the PED within 72 hours for persistent symptoms. A secondary analysis was performed on patients with a diagnoses of head injury who did not receive a head CT and were discharged. RESULTS: A total of 6311 patients had a diagnosis of head injury, had a head CT performed, and were discharged from the PED. The use of ondansetron increased significantly from 3.7% in 2003 to 22% in 2010 (P < .001). After controlling for demographic/acuity differences, receiving ondansetron in the PED was associated with a lower likelihood of returning within 72 hours (0.49, 95% confidence interval [0.26-0.92]). In patients with head injury who did not have a head CT performed and were sent home, the use of ondansetron in the PED was not associated with an increased risk of missed diagnoses. CONCLUSION: Ondansetron use in children with a CT scan who are dispositioned home is relatively safe, does not appear to mask any significant conditions, and significantly reduces return visits to the PED.

Acute neck infections in children: who is likely to undergo surgical drainage?

BACKGROUND: Superficial neck infections including lymphadenitis and abscesses are commonly encountered in pediatric emergency departments (PEDs). It is often unclear which patients are likely to develop an abscess that necessitates surgical drainage. In evaluating these patients, computed tomography (CT) and ultrasound are often used to identify/confirm abscess formation. The criteria for determining the need for imaging studies are not well defined. DESIGN/METHODS: All visits to the study PED were examined in 2009 to 2010. Visits with the diagnosis of cervical lymphadenitis or abscess were identified. Records were retrospectively reviewed to determine the duration of symptoms, fever, previous antibiotic therapy, prior PED visit, size of neck swelling, fluctuance on physical examination, white blood cell count, and results of CT and/or ultrasound obtained in the PED. Data were analyzed to determine which of these characteristics were more likely to be associated with an abscess that was operatively drained. RESULTS: A total of 768 patients were evaluated for neck infections. One hundred twelve (14%) of these pediatric patients underwent abscess drainage in the operating room. Two hundred eighty-nine patients underwent a neck CT and/or ultrasound, of which 119 were positive for abscess. Factors associated with surgical drainage included fluctuance (odds ratio [OR], 18.92; 95% confidence interval [CI], 3.66-31.37), previous emergency department visit (OR, 2.79; 95% CI, 1.34-5.84), and age less than 4 years (OR, 3.01; 95% CI, 1.15-9.87). A recursive partitioning model stratified patients' risk for going to the operating room. Patients without fluctuance and with no prior emergency department visit, along with no prior antibiotic use, have less than 4% chance of having an abscess that necessitates surgical drainage. CONCLUSIONS: Pediatric patients who are more likely to have a neck infection that necessitates surgical drainage can be stratified based on clinical characteristics. This knowledge may allow physicians to better predict the resource needs including hospital admission and emergent imaging for neck infection.

Preliminary validation of a structural magnetic resonance imaging metric for tracking dementia-related neurodegeneration and future decline.

Alzheimer's disease (AD) is a progressive neurodegenerative disease characterized by cognitive decline and atrophy in the medial temporal lobe (MTL) and subsequent brain regions. Structural magnetic resonance imaging (sMRI) has been widely used in research and clinical care for diagnosis and monitoring AD progression. However, atrophy patterns are complex and vary by patient. To address this issue, researchers have made efforts to develop more concise metrics that can summarize AD-specific atrophy. Many of these methods can be difficult to interpret clinically, hampering adoption. In this study, we introduce a novel index which we call an "AD-NeuroScore," that uses a modified Euclidean-inspired distance function to calculate differences between regional brain volumes associated with cognitive decline. The index is adjusted for intracranial volume (ICV), age, sex, and scanner model. We validated AD-NeuroScore using 929 older adults from the Alzheimer's Disease Neuroimaging Initiative (ADNI) study, with a mean age of 72.7 years (SD = 6.3; 55.1-91.5) and cognitively normal (CN), mild cognitive impairment (MCI), or AD diagnoses. Our validation results showed that AD-NeuroScore was significantly associated with diagnosis and disease severity scores (measured by MMSE, CDR-SB, and ADAS-11) at baseline. Furthermore, baseline AD-NeuroScore was associated with both changes in diagnosis and disease severity scores at all time points with available data. The performance of AD-NeuroScore was equivalent or superior to adjusted hippocampal volume (AHV), a widely used metric in AD research. Further, AD-NeuroScore typically performed as well as or sometimes better when compared to other existing sMRI-based metrics. In conclusion, we have introduced a new metric, AD-NeuroScore, which shows promising results in detecting AD, benchmarking disease severity, and predicting disease progression. AD-NeuroScore differentiates itself from other metrics by being clinically practical and interpretable.

Use of troponin as a screen for chest pain in the pediatric emergency department.

Troponin levels are commonly employed in the assessment of adults presenting with chest pain or concern for coronary ischemia. However, the utility of troponin measurements in children is not well defined. The purpose of this study was to review the use and clinical yield of serum troponin assay in a large pediatric emergency department (ED). We identified all patients <22 years of age, not previously known to have cardiac disease, who presented with chest pain and whose troponin levels were evaluated in our pediatric ED during a 7-year period. Test results were correlated to patient factors, such as chief complaint, cardiac history, diagnostic workup, and discharge diagnoses. Of the 212 study patients who presented with chest pain, troponin levels were increased (≥ 0.1 ng/ml) in 37 (17%) subjects. The disposition for these 37 subjects included transfer to adult facility (n = 6), admission to our pediatric inpatient service (n = 27), and discharge to home from the ED (n = 10). Only one subject had an acute myocardial infarction. For those with increased troponin level, 18 of 37 (48%) cases were attributed to a primary cardiac diagnosis with the most common discharge diagnosis of myocarditis or pericarditis. In the pediatric ED setting, selective use of troponin assay may be a useful test in the management of patients with chest pain. Most cases of increased troponin level related to chest pain represent myocarditis, often mild and self-resolving. Given the low likelihood that acute coronary syndrome is the etiology of chest pain, immediate transfer to an adult facility for the majority of patients with increase of troponin does not appear warranted.

Ondansetron use in the pediatric emergency room for diagnoses other than acute gastroenteritis.

BACKGROUND: Ondansetron is widely used in the pediatric emergency department (PED) for vomiting and acute gastroenteritis (GE). Little is known about the spectrum of its use in diagnoses other than acute GE. OBJECTIVE: The objective of this study was to evaluate the spectrum of diagnoses for which ondansetron is used in the PED. METHODS: Medical records from 2 tertiary care PEDs from January 2006 to December 2008 were retrospectively reviewed. Patients 3 months to 18 years of age given ondansetron in the PED were identified. Patients without a primary discharge diagnosis (based on International Classification of Diseases, Ninth Revision code) of vomiting or GE were defined as non-GE. Patient age, initial triage level (1 = lowest acuity, 5 = highest), route of administration (enteral vs parenteral), primary diagnosis, disposition, and prescription for ondansetron at discharge were recorded; GE and non-GE patients were compared based on age and triage acuity. RESULTS: There were 32,971 patients who received ondansetron in the PED; 12,620 (38%) were non-GE patients. Non-GE patients were older (8.3 vs 4.3 years, P < 0.001) and of higher average initial triage level (2.95 vs 2.33, P < 0.001) compared with GE patients. Within non-GE patients, 79% received ondansetron enterally, 71% were discharged, and 37% of those discharged received an ondansetron prescription. The most common primary diagnoses for non-GE discharged patients were fever (15%), abdominal pain/tenderness (13%), head injury/concussion (7%), pharyngitis (6%), viral infection (6%), migraine variants (5%), and otitis media (5%). The most common diagnoses of patients admitted were appendicitis (11%), asthma (6%), pneumonia (4%), and diabetes (4%). CONCLUSIONS: Although ondansetron is a widely accepted treatment for GE in children, this study identifies a broader spectrum of primary diagnoses for which ondansetron is being used.

Management of afebrile neonates with skin and soft tissue infections in the pediatric emergency department.

OBJECTIVE: To describe the management of afebrile neonatal skin and soft tissue infections (SSTIs) in the pediatric emergency department (PED). METHODS: This is a retrospective cohort study of all patients aged 0 to 28 days seen in the PED for SSTIs from 2004 to 2010. The SSTIs were identified from the International Classification of Diseases, Ninth Revision codes of pustulosis, cellulitis, and abscess. Records were reviewed to determine the absence of fever; anatomical location; cultures of blood, urine, and cerebrospinal fluid; antibiotic usage; and return visits. Data were analyzed to compare admitted versus discharged patients with SSTI subtypes. RESULTS: Of the 136 neonates identified, 104 met inclusion criteria. Afebrile SSTIs included 8 pustulosis, 45 cellulitis, and 51 abscesses. Blood cultures were obtained in 13% of pustulosis, 96% of cellulitis, and 69% of abscesses. No serious bacterial infection was noted. Three blood cultures grew contaminants. Parenteral antibiotics for neonates with pustulosis, cellulitis, and abscesses were given in 13%, 87%, and 59%, respectively. Admission rates for neonates with pustulosis, cellulitis, and abscesses were 13%, 84%, and 55%, respectively. Cases of cellulitis were more likely to have blood cultures drawn (odds ratio [OR], 13.7; 95% confidence interval [CI], 3.03-62.3), receive intravenous antibiotics (OR, 5.87; 95% CI, 2.16-15.0), and be admitted to the hospital (OR, 5.62; 95% CI, 2.16-14.6) as compared with the other SSTI subtypes. CONCLUSIONS: None of the neonates who had cultures drawn had serious bacterial infection. The SSTI subtype correlated with the extent of evaluation and dispositions. The findings of this study will help with management strategies for afebrile neonates with SSTIs in the PED.

Effects of a system-wide fracture care program to enhance access and follow-up for orthopedics.

OBJECTIVES: Fractures of the extremities are commonly encountered in pediatric emergency departments (PEDs) nationwide. These fractures can lead to bone malformation and deformities if not managed properly. There are multiple barriers to obtaining necessary outpatient follow-up for fracture care, which leads to increased return to the PED for management. Because of these barriers, a "Fracture Care Program" was implemented at the study hospital's network. This study aimed to determine implementation of a Fracture Care Program would lead to reduced PED utilization. METHODS: All visits to the study PEDs were examined from January 1 to August 30, 2010. At PED discharge, patients were given a Fracture Care Program handout, which outlined step-by-step instructions for identifying and scheduling an appointment with a local orthopedic surgeon as an outpatient. A telephone hotline number was also provided where they could speak with a representative of the orthopedics department for assistance in obtaining follow-up. Detailed records were reviewed to determine whether these instructions were associated with lower rates of return. RESULTS: A total of 2120 patients met inclusion criteria. Of these, 1233 (58%) received the Fracture Care discharge instructions. After controlling for differences in payor status and demographic differences, patients who received instructions were less likely to return to the PED (odds ratio, 0.616; 95% confidence interval, 0.40-0.95) within 30 days for orthopedic care than patients who did not receive the instructions. CONCLUSIONS: This systematic coordination of services of a large tertiary care pediatric health care system, local pediatric orthopedic surgery private practices, academic practices, and hospital-affiliated practices improved overall access for families related to orthopedic follow-up care. This model may also aid in helping to improve follow-up in other pediatric subspecialties.

Pediatric abscess characteristics associated with hospital admission from the ED.

OBJECTIVE: To determine the characteristics of pediatric soft tissue abscesses that result in hospital admission. METHODS: All visits for soft tissue abscesses to the study emergency department (ED) were examined during 2008. Detailed records were reviewed to determine ED disposition, abscess size, location, presence of fever, duration of symptoms, previous antibiotic therapy, prior ED visit(s), and wound and blood culture results. Data were analyzed to determine which of these characteristics were associated with hospital admission from the ED. RESULTS: Six hundred twenty-two patients met the inclusion criteria. One hundred thirteen (18%) patients were admitted to the hospital and 509 (82%) were discharged home. Compared to those sent home, abscesses resulting in admission were more likely to be located in the genital area (odds ratio [OR], 3.08; 95% confidence interval [CI], 1.37-6.90), breast (OR, 4.8; 95% CI, 1.08-21.4), or face (OR, 4.39; 95% CI, 1.86-10.3), and were more likely to be larger than 3 cm (OR, 3.66, 95% CI, 2.10-6.36). Patients who were admitted to the hospital were also more likely to have fever (OR, 5.93; 95% CI, 3.4-10.3) and have had a prior ED visit with the same complaint (OR, 3.81; 95% CI, 1.77-8.2). Seventy-seven percent of abscesses that were cultured were positive for methicillin-resistant Staphylococcus aureus. CONCLUSIONS: Size and location (especially those in the genital region, breast, and face), appear to be associated with admission for pediatric abscesses. History of fever and previous ED visit also appear to be associated with hospital admission. Obtaining blood cultures for pediatric abscesses is likely of little clinical benefit.

Cardiac disease in pediatric patients presenting to a pediatric ED with chest pain.

BACKGROUND: Chest pain is a frequent chief complaint among the pediatric population. To date, limited data exist on the full spectrum of emergent cardiac disease among such patients; and existing data have been limited to relatively small cohorts. OBJECTIVES: The aims of the study were to investigate the emergent cardiac etiologies of chest pain in a large cohort of patients presenting to a tertiary care pediatric emergency department (PED) and to examine the use of resources (electrocardiogram, chest radiograph, echocardiogram, and laboratories) in those with and without cardiac-related chest pain. METHODS: Patient visits to 2 tertiary care PEDs were evaluated over a 3 and half-year period. Records of patients less than 19 years of age with a chief complaint of chest pain and no history of cardiovascular disease were reviewed. Patients were categorized as having cardiac or noncardiac etiologies or history of cardiovascular disease at the time of discharge, based on PED attending's final diagnoses. Final diagnoses classified as emergent cardiac etiologies were determined a priori. RESULTS: Four thousand four hundred thirty-six patients reported a chief complaint of chest pain during the study period. Three percent were excluded secondary to a history of heart disease. Only 24 (0.6%) of the remaining 4288 were determined to have chest pain of cardiac origin. Those with cardiac-related chest pain had a rate of admission of 50% compared to those without cardiac disease at 4% (P < .001). Nine patients had an arrhythmia, 6 had pericarditis, 4 had myocarditis, 3 had acute myocardial infarction, and 1 had pulmonary embolism and pneumopericardium. Ninety-two percent of the cardiac-related chest pain cohort received electrocardiograms compared to those without cardiac-related chest pain at 27% (P < .01). Only 1 (4%) of 24 subjects with cardiac-related chest pain had a prior emergency department visit within 72 hours suggesting a high detection rate upon initial presentation. The most common noncardiac etiologies for the chest pain were 56% musculoskeletal disorders; 12% related to wheezing, asthma, and cough; 8% infectious causes; 6% gastrointestinal; and 4% related to sickle cell anemia. CONCLUSION: Cardiac-related chest pain in pediatric patients is rare but potentially serious. Arrhythmia was the most common cardiac-related etiology among this cohort. Those with myocarditis and myocardial infarction were the most acutely ill. An electrocardiogram in addition to history and physical examination was most useful in detecting relatively uncommon but significant cardiac-related chest pain. Using a thorough physical examination and potentially an electrocardiogram evaluation by a pediatric emergency care physician has an excellent rate of detection of cardiac-related causes.

Ondansetron use in the pediatric emergency department and effects on hospitalization and return rates: are we masking alternative diagnoses?

STUDY OBJECTIVE: We evaluate the effect of ondansetron use in cases of suspected gastroenteritis on the proportion of hospital admissions and return visits and assess whether children who receive ondansetron on their initial visit to the pediatric emergency department (ED) for suspected gastroenteritis return with an alternative diagnosis more frequently than those who did not receive ondansetron. METHODS: This is a retrospective review of visits to 2 tertiary care pediatric EDs with an International Classification of Diseases, Ninth Revision diagnosis of vomiting or gastroenteritis. A logistic regression model was developed to determine the effect of ondansetron use during the initial pediatric ED visit on hospital admission, return to the pediatric ED within 72 hours, and admission on this return visit. For patients who returned within 72 hours and were admitted, hospital discharge records were reviewed. The proportions of alternative diagnoses, defined as a hospital discharge diagnosis that was not a continuation of gastroenteritis or vomiting, were compared between the groups. RESULTS: During the 3-year study period (2005 to 2007), 34,117 patients met study criteria. Ondansetron was used for 19,857 (58.2%) of these patients on their initial pediatric ED visit. After controlling for differences between the groups, patients who received ondansetron were admitted on their initial visit less often: odds ratio (OR) 0.47 (95% confidence interval [CI] 0.42 to 0.53). However, those who received ondansetron were more likely to return to the pediatric ED within 72 hours (OR 1.45; 95% CI 1.27 to 1.65) and be admitted on the return visit (OR 1.74; 95% CI 1.39 to 2.19). The proportions of alternative diagnoses at hospital discharge were not significantly different in the group that received ondansetron on the initial pediatric ED visit (14.9%) compared with the group that did not (22.4%) (absolute difference 7.5% [95% CI -0.5% to 16.4%). CONCLUSION: Ondansetron use in the pediatric ED reduces hospital admissions for suspected gastroenteritis and vomiting. However, children who receive ondansetron in the pediatric ED appear more likely to return to the pediatric ED and be admitted on this return visit than their counterparts. Furthermore, the use of ondansetron does not appear to be associated with increased risks of masking serious diagnoses in children.

Pandemic H1N1 influenza in the pediatric emergency department: a comparison with previous seasonal influenza outbreaks.

STUDY OBJECTIVE: We compare the acuity of pediatric emergency department (ED) patients between the ongoing H1N1 influenza pandemic and previous seasonal influenza outbreaks. METHODS: An observational, cross-sectional analysis of patient visits at 2 pediatric tertiary care EDs was made for the following periods: (1) regional fall 2009 H1N1 influenza surge (August 17 to September 20, 2009), and (2) combined regional 2007 to 2009 early peak influenza seasons (January 28 to March 2, 2008, and February 2 to March 8, 2009). Proportions of admissions, return visits, and return visits resulting in admission were compared between the 2 periods. Subset analysis of patients with influenza-like illness was performed. RESULTS: Of total visits, no difference was found in the proportions of hospital admissions between the 2009 H1N1 surge (18,503 visits) and the previous influenza seasons (29,002 visits): non-ICU 9.9% versus 10.4%, 95% confidence interval of the difference -0.07% to 1.0%; ICU 0.9% versus 0.9%, 95% CI of the difference -0.1% to 0.2%. Of patients with influenza-like illness, no difference was found in the proportions of non-ICU admissions between the 2009 H1N1 surge (7,064 visits) and the previous influenza seasons (8,489 visits): 4.8% versus 5.2%, 95% CI of the difference -0.3% to 1.1%, whereas the proportion of ICU admissions increased during the 2009 H1N1 surge: 0.3% versus 0.1%, 95% CI of the difference 0.05% to 0.4%. The proportions of return visits within 7 days, including those resulting in admission, were similar between the 2 periods for both the total ED population and the influenza-like illness subset. CONCLUSION: The severity of illness during the 2009 H1N1 surge appeared similar to that of previous influenza seasons for the total population of the 2 pediatric tertiary care EDs, whereas an increase in the proportion of ICU admissions was observed for patients with influenza-like illness.

Potential impact of peripheral intravenous catheter placement on resource use in the pediatric emergency department.

OBJECTIVES: In an era of pediatric emergency department (PED) overcrowding and diminishing health care resources, routine peripheral intravenous (PIV) catheter placement in the pediatric population requires evaluation because it might directly impact PED efficiency. This study aims to determine the utility of routine PIV catheter placement during phlebotomy. METHODS: Electronic medical and billing records from 2 tertiary care PEDs during 1 year in patients 21 years or younger were analyzed. Data on the presence of PIV catheter placement in the PED, subsequent PIV catheter usage, chief complaint, and demographics were tabulated and analyzed. RESULTS: During the study period, there were 131,003 PED visits analyzed and 26,776 PIV catheters placed. Of those placed, 12,475 (47%) were not used. The median age of the patients who received a PIV catheter that was not subsequently used was 36 months. The frequency of unused PIV catheters correlates with lower initial triage acuity. The highest rate of unused PIV catheter was in those 1 to 6 months old (63%), followed by that in groups younger than 1 month (57%), older than 6 to 24 months (52%), and older than 24 months (41%). CONCLUSIONS: Nearly half of the PIV catheters placed in the PED were unused. Unused PIV catheters represent an inefficient use of limited resources that could be redistributed to improve ED efficiency, flow, and resource use.

Pediatric emergency department overcrowding: electronic medical record for identification of frequent, lower acuity visitors. Can we effectively identify patients for enhanced resource utilization?

The objective of this study was to utilize the electronic medical record system to identify frequent lower acuity patients presenting to the Pediatric Emergency Department and to evaluate their impact on Pediatric Emergency Department overcrowding and resource utilization. The electronic medical records (EMR) of two pediatric emergency centers were reviewed from August 2002 to November 2004. Pediatric Emergency Department encounters that met any of the following criteria were classified as Visits Necessitating Pediatric Emergency Department care (VNEC): Disposition of admission, transfer or deceased; Intravenous fluids (IVF) or medications (excluding single antipyretic or antihistamine); Radiology or laboratory tests (excluding Rapid Strep); Fractures, dislocations, and febrile seizures. All other visits were classified as non-VNEC. ICD-9 (International Classification of Diseases, Ninth Revision) codes from the Pediatric Emergency Department encounters were defined as representing chronic or non-chronic conditions. Patients were then evaluated for utilization patterns, frequency of Emergency Department (ED) visits, chronic illness, and VNEC status. There were 153,390 patients identified, representing 255,496 visits (1.7 visits/patient, range 1-49). Overall, 189,998 visits (74%) required defined ED services and were categorized as VNEC, with the remaining 65,498 visits (26%) categorized as non-VNEC. With increasing visits, a steady decline in those requiring ED services was observed, with a plateau by visit six (VNEC 77% @ one visit, 64% @ six visits, p < 0.001). There were 141,765 patients seen fewer than four times, representing 92% of the patients and 74% of all visits (1.3 visits/patient, 225 visits/day). In contrast, 2664 patients disproportionately utilized the ED more than six times (maximum 49), representing 1.7% of patients and 9.8% of visits (9.4 visit/patient, 30 visits/day, p < 0.001). Excluding patients with chronic illness, 1074 patients also disproportionately utilized the ED more than six times (maximum 28), representing 0.7% of patients and 3.6% of visits (8.6 visit/patient, 11 visits/day, p < 0.001). While representing < 2% of patients, frequent lower acuity utilizers of ED services accounted for nearly 10% of all visits (30/day). Low acuity patients may require only limited additional marginal resources for their individual care. However, in aggregate, inefficiencies occur, especially when systems reach capacity constraints, at which point these patients utilize limited resources (manpower and space) that could more effectively be directed toward the more acutely ill and injured patients. Therefore, identification of these patients utilizing the electronic medical record will allow for targeted interventions of this subgroup to improve future resource allocation.

Access to outpatient follow-up orthopedic care after pediatric emergency department visits: impact of implementation of a managed Medicaid program.

OBJECTIVE: A Medicaid managed care (MMC) program was instituted regionally with the goal of improving quality and access to care for underserved populations. The purpose of this study was to determine whether the implementation of an MMC program has affected access to timely orthopedic follow-up care. METHODS: All visits to 2 tertiary care pediatric emergency departments (PED) with a diagnosis of extremity fracture or dislocation were examined for a 5-month period after implementation of MMC and compared with the same periods during 2004 and 2005. Repeat visits for orthopedic concerns to the PED within 30 days of the initial fracture care were compared across the pre- and post-MMC periods. RESULTS: Six thousand four hundred nine visits with a diagnosis of extremity fracture or dislocation were identified (4110 in the two 5-month pre-MMC periods and 2299 in the 5-month post-MMC period). A total of 167 return visits for orthopedic concerns were identified in the pre-MMC period (4.0%) compared with 150 return visits in the post-MMC period (6.5%) (P<0.001). Of these, 12 (7.2%) in the pre-MMC period and 55 (36.6%) in the post-MMC period were identified as related to the inability to access outpatient orthopedic follow-up (P<0.001). In both periods, Medicaid patients were more likely to return to the PED for inability to access care, compared with privately insured patients (odds ratio [OR], 6.1; 95% confidence interval [CI], 3.54-10.32). CONCLUSIONS: After the implementation of a regional MMC program, patients were increasingly unable to access routine outpatient follow-up. This may shift additional cost and resource load to PED, while limiting access to vital services for medically vulnerable patients.

Return to the emergency department after ventricular shunt evaluation.

OBJECT Patients with CSF shunts are medically complex and frequently present to the emergency department (ED) with suspected shunt malfunction. After adequate evaluation in the ED and proper disposition, some patients return to the ED within a short period of time. In this study, the authors examined the reasons for ED revisits within 7 days of the index ED visit to discern possible preventable returns. METHODS There were 3080 index ED visits made by patients with shunted hydrocephalus between 2010 and 2013. Index ED visits preceded by another ED visit or neurosurgical procedure within 60 days were excluded. Index ED visits for reasons unrelated to shunt function and those that led directly to admissions and shunt revision surgeries were also excluded. The remaining 1509 ED visits were eligible for analysis in this study. Final dispositions from the index ED visit included home (1176 cases), admission to the neurosurgery service for observation (134 cases), and admission to other services (199 cases). Subsequent events within 7 days, including ED revisits, hospital admissions, and shunt-related surgery were recorded, and reasons for the ED revisits were categorized based on whether the visit was related to shunt function concerns. Clinical and socioeconomic factors were analyzed for their association with ED revisits by using statistical methods. RESULTS Of the 1176 patients discharged home from the ED after shunt function evaluation, 101 (8.6%) returned to the ED within 7 days. Of the 134 patients admitted to the neurosurgery service for observation only, 8 (6.0%) returned to the ED within 7 days of discharge. Of the 199 patients admitted to hospital services other than neurosurgery, 13 (6.5%) returned to the ED within 7 days of discharge. The reasons for ED revisits vary (total of 122 visits combining the 3 groups), but at least 60% of the revisits were clearly unrelated to shunt function. A younger age, daytime arrival to the ED, and living within the metropolitan area were identified as risk factors for ED revisits. CONCLUSIONS Children with CSF shunts are medically complex and use ED services often. After an index ED visit at which shunt function was deemed to be the chief concern, the purpose of the subsequent return to the ED within 7 days was often for complaints unrelated to shunt function. Caution is warranted when attempting to classify these complex patients as having potential preventable return-to-system events.

Cloud-based Predictive Modeling System and its Application to Asthma Readmission Prediction.

The predictive modeling process is time consuming and requires clinical researchers to handle complex electronic health record (EHR) data in restricted computational environments. To address this problem, we implemented a cloud-based predictive modeling system via a hybrid setup combining a secure private server with the Amazon Web Services (AWS) Elastic MapReduce platform. EHR data is preprocessed on a private server and the resulting de-identified event sequences are hosted on AWS. Based on user-specified modeling configurations, an on-demand web service launches a cluster of Elastic Compute 2 (EC2) instances on AWS to perform feature selection and classification algorithms in a distributed fashion. Afterwards, the secure private server aggregates results and displays them via interactive visualization. We tested the system on a pediatric asthma readmission task on a de-identified EHR dataset of 2,967 patients. We conduct a larger scale experiment on the CMS Linkable 2008-2010 Medicare Data Entrepreneurs' Synthetic Public Use File dataset of 2 million patients, which achieves over 25-fold speedup compared to sequential execution.