A Comparison of State-Specific Pediatric Emergency Medical Facility Recognition Programs, 2020.

OBJECTIVES: Prior research suggests that the presence of state-specific pediatric emergency medical facility recognition programs (PFRPs) is associated with high emergency department (ED) pediatric readiness. The PFRPs aim to improve the quality of pediatric emergency care, but individual state programs differ. We aimed to describe the variation in PFRP characteristics and verification requirements and to describe the availability of pediatric emergency care coordinators (PECCs) in states with PFRPs. METHODS: In mid-2020, we collected information about each PFRP from 3 sources: the state Emergency Medical Services for Children (EMSC) website, the EMSC Innovation and Improvement Center website, or via communication with the state's EMSC program manager. For each state with a PFRP, we documented program characteristics, including program start date, number of tiers, whether participation was required/optional, and requirements for verification. RESULTS: Overall, we identified 17 states with active PFRPs. Five states had only 1 tier or level of recognition whereas the others had multiple. All programs did require presence of a PECC for verification. However, some PRFPs with multiple verification tiers did not require presence of a PECC to achieve each level of verification. In states with PFRPs, EDs with higher total visit volumes, a separate pediatric ED area, located in the Northeast, and earlier program start date were all more likely to have a PECC. CONCLUSIONS: There is variation in state PFRPs, although all prioritize the presence of a PECC. We encourage further research on the effect of different aspects of PFRPs on patient outcomes.

Change in Emergency Medical Services-Attended Out-of-Hospital Deliveries during COVID-19 in the United States.

BACKGROUND: The COVID-19 pandemic disrupted access to routine in-person prenatal care, potentially leading to higher risk of out-of-hospital deliveries. Unplanned out-of-hospital deliveries pose a substantial risk of morbidity and mortality for pregnant patients and newborns. Our objective was to determine the change in rate of emergency medical services (EMS)-attended out-of-hospital deliveries during the COVID-19 pandemic. We hypothesized that COVID-19-related stay-at-home orders were associated with a higher rate of out-of-hospital deliveries during the initial wave of COVID-19. METHODS: We conducted an interrupted time series analysis using the 2019 and 2020 National EMS Information System datasets. We included 9-1-1 scene activations for patients 12-50 years old with out-of-hospital deliveries who were treated and transported by EMS. We calculated the weekly rate of deliveries per 100,000 EMS emergency activations each year overall, and for each census division. The interruption modeled was the enactment of stay-at-home orders, with March 25-31 selected as when most orders had been enacted. We fit ordinary least squares regression models with Newey-West standard errors to adjust for autocorrelation, testing for a change in level and slope overall and by census division. RESULTS: A total of 10,778 out-of-hospital deliveries were included, 58% (n = 6,254) in 2020. The mean weekly rate of out-of-hospital deliveries in 2019 was 29.4 per 100,000 activations (95% CI: 28.4 to 30.4) versus 33.0 (95% CI: 31.8 to 34.1) in 2020. There was an immediate increase of 6.3 deliveries per 100,000 activations (95% CI: 3.3 to 9.3) after the week of March 25-31, with a subsequent decrease of 0.3 deliveries per 100,000 per week after (95% CI: -0.4 to -0.2). There were also statistically significant immediate increases in out-of-hospital deliveries after March 25-31 in the New England, East North Central, West South Central, and Mountain divisions. CONCLUSION: EMS-attended out-of-hospital deliveries remained rare during the COVID-19 pandemic, but there was an immediate increase during the initial wave of the pandemic with evidence of geographic variation. Large-scale disruptions in the health care system may result in increases in uncommon patient presentations to EMS.

Epidemiology of Emergency Medical Services-Attended out-of-Hospital Deliveries and Complications in the United States.

BACKGROUND: Prehospital obstetric events, including out-of-hospital deliveries and their complications, are a rare but high-risk event encountered by emergency medical services (EMS). Understanding the epidemiology of these encounters would help identify strategies to improve prehospital obstetric care. Our objective was to determine the characteristics of out-of-hospital deliveries and high-risk complications treated by EMS clinicians in the U.S. METHODS: We conducted a cross-sectional analysis of EMS patient care records in the 2018 and 2019 National EMS Information System Public Release Version 3.4 datasets. We included EMS activations after a 9-1-1 scene response for patients aged 12-50 years with evidence of an out-of-hospital delivery or delivery complication, or where the patient was a newborn aged 0-<6 h. We examined patient, community, emergency response, and clinical characteristics using descriptive statistics. RESULTS: Of the 56,735,977 EMS activations included in the 2018 and 2019 datasets, there were 8,614 out-of-hospital deliveries, 1,712 delivery complications, and 5,749 records for newborns. Most maternal (76%) out-of-hospital deliveries involved patients between the ages of 20-34 years, occurred on a weekday (73%), were treated by an advanced life support crew (85%), and occurred in a home or residence (73%). EMS-assisted field delivery was documented in 3,515 (34%) of all maternal activations but only 2% of activations with a delivery complication. Few patients received an EMS-administered medication (e.g., 0.4% received oxytocin). Supplemental oxygen was administered in 870 (15%) of newborn activations. Activations from counties with the most racial/ethnic diversity were more often treated by a BLS-level unit (16% vs. 12%, p < 0.001), and activations from rural areas had significantly longer transport times (19.7 min [IQR 8.7, 32.8] vs. urban, 13.1 min [IQR 8.7, 19.7], p < 0.001). CONCLUSION: In this large, national repository of EMS patient care records from across the U.S., most activations for out-of-hospital delivery, delivery complication, or a newborn included only routine EMS care. There were potential disparities in level of care, clinical care provided, and measures of access to definitive care based on maternal and community factors. We also identified gaps in current practice, such as for postpartum hemorrhage, that could be addressed with changes in EMS clinical protocols and regulations.

Trends in female first-author abstracts at the Society for Academic Emergency Medicine Annual Meeting, 1990-2020.

OBJECTIVES: To describe first author gender differences and characteristics in 1) Society for Academic Emergency Medicine (SAEM) Annual Meeting abstracts and 2) resulting manuscript publications. METHODS: We performed cross-sectional evaluation of SAEM abstracts from 1990, 1995, 2000, 2005, 2010, 2015, and 2020, compiling and reviewing a random sample of 100 abstracts for each year (total n = 700 abstracts). We documented abstract characteristics, including first author gender, and used the 2020 SAEM scoring rubric. We then searched PubMed to identify manuscript publications resulting from abstracts from 1990 to 2015 (n = 600). Finally, among abstracts that resulted in manuscript publication, we identified first and last author gender on both the abstracts and the resulting publication. RESULTS: Overall, 29% (202/695; n = 5 missing gender) of abstracts had female first authors. Female first authors increased over time (e.g., 17% in 1990 to 35% in 2020). Abstract quality scores were similar (both median [interquartile range] of 11 ([9-12]). Overall, 42% (n = 254/600) of abstracts resulted in a manuscript publication, 39% (n = 65/202) with female and 44% (n = 189/493) with male first authors (p = 0.26). The median time (IQR) from abstract to manuscript publication was longer for abstracts with female first authors vs. those with male first authors (2 [1-3] years and 1 [1, 2] years, p < 0.02); 77% and 78% of publications resulting from abstracts with female and male first authors, respectively, had the same first author. Female first author abstracts more often converted to a male first author manuscript publication (18%, n = 12/65) compared to male first author abstracts converting to female first author publications (7%, n = 14/189). CONCLUSIONS: A minority of SAEM abstracts, and manuscript publications resulting from them, had female first authors. Abstracts with female first authors took longer to achieve manuscript publication, and almost a fifth of female first author abstracts resulted in male first author manuscript publication.

Pediatric Patient Insurance Status and Regionalization of Admissions.

BACKGROUND: Pediatric hospital care is becoming increasingly regionalized, and previous data have suggested that insurance may be associated with transfer. The aims of the study are to describe regionalization of pediatric care and density of the interhospital transfer network and to determine whether these varied by insurance status. METHODS: Using the New York State ED Database and State Inpatient Database from 2016, we identified all pediatric patients and calculated regionalization indices (RI) and network density, overall and stratified by insurance. Regionalization indices are based on the likelihood of a patient completing care at the initial hospital. Network density is the proportion of actual transfers compared with the number of potential hospital transfer connections. Both were calculated using the standard State ED Database/State Inpatient Database transfer definition and in a sensitivity analysis, excluding the disposition code requirement. RESULTS: We identified 1,595,566 pediatric visits (emergency department [ED] or inpatient) in New York in 2016; 7548 (0.5%) were transferred and 7374 transferred visits had eligible insurance status (Medicaid, private, uninsured). Of the transfers, 24% were from ED to ED with discharge, 28% from ED to ED with admission, 31% from ED to inpatient, 16% from inpatient to inpatient, and 1.2% from inpatient to ED. The overall RI was 0.25 (95% confidence interval [95% CI], 0.20-0.31). The overall weighted RI was 0.09 (95% CI, 0.06-0.12) and was 0.09 (95% CI, 0.06-0.13) for Medicaid-insured patients, 0.08 (95% CI, 0.05-0.11) for privately insured patients, and 0.08 (95% CI, 0.05-0.11) for patients without insurance. The overall network density was 0.018 (95% CI, 0.017-0.020). Network density was higher, and transfer rates were lower, for patients with Medicaid insurance as compared with private insurance. CONCLUSIONS: We found significant regionalization of pediatric emergency care. Although there was not material variation by insurance in regionalization, there was variation in network density and transfer rates. Additional work is needed to understand factors affecting transfer decisions and how these patterns might vary by state.

Availability of Pediatric Emergency Care Coordinators in US Emergency Departments in 2018.

OBJECTIVES: In 2007, the US Institute of Medicine recommended that every emergency department (ED) appoint pediatric emergency care coordinators (PECCs). Despite this recommendation, our national surveys showed that few (17%) US EDs reported at least 1 PECC in 2015. This number increased slightly to 19% in 2016 and 20% in 2017. The current study objectives were to determine the following: percent of US EDs with at least 1 PECC in 2018, factors associated with availability of at least 1 PECC in 2018, and factors associated with addition of at least 1 PECC between 2015 and 2018. METHODS: In 2019, we conducted a survey of all US EDs to characterize emergency care in 2018. Using the National ED Inventory-USA database, we identified 5514 EDs open in 2018. This survey collected availability of at least 1 PECC in 2018. A similar survey was administered in 2016 and identified availability of at least 1 PECC in 2015. RESULTS: Overall, 4781 (87%) EDs responded to the 2018 survey. Among 4764 EDs with PECC data, 1037 (22%) reported having at least 1 PECC. Three states (Connecticut, Massachusetts, and Rhode Island) had PECCs in 100% of EDs. The EDs in the Northeast and with higher visit volumes were more likely to have at least 1 PECC in 2018 (all P < 0.001). Similarly, EDs in the Northeast and with higher visit volumes were more likely to add a PECC between 2015 and 2018 (all P < 0.05). CONCLUSIONS: The availability of PECCs in EDs remains low (22%), with a small increase in national prevalence between 2015 and 2018. Northeast states report a high PECC prevalence, but more work is needed to appoint PECCs in all other regions.

Pediatric Telehealth Use in U.S. Emergency Departments in 2019.

Objectives: Little is known about the recent usage of pediatric telehealth across all emergency departments (EDs) in the United States. Building upon our prior work, we aimed to characterize the usage of ED pediatric telehealth in the pre-COVID-19 era. Methods: The 2019 National ED Inventory-USA survey characterized all U.S. EDs open in 2019. Among EDs reporting receipt of pediatric telehealth services, we selected a random sample (n = 130) for a second survey on pediatric telehealth usage (2019 ED Pediatric Telehealth Survey). We also recontacted a random sample of EDs that responded to a prior, similar 2017 ED Pediatric Telehealth Survey (n = 107), for a total of 237 EDs in the 2019 ED Pediatric Telehealth Survey sample. Results: Overall, 193 (81%) of the 237 EDs responded to the 2019 Pediatric Telehealth Survey. There were 149 responding EDs that confirmed pediatric telehealth receipt in 2019. Among these, few reported ever having a pediatric emergency medicine (PEM) physician (10%) or pediatrician (9%) available for emergency care. Although 96% of EDs reported availability of pediatric telehealth services 24 h per day, 7 days per week, the majority (60%) reported using services less than once per month and 20% reported using services every 3-4 weeks. EDs most frequently used pediatric telehealth to assist with placement and transfer coordination (91%). Conclusions: Most EDs receiving pediatric telehealth in 2019 had no PEM physician or pediatrician available. Most EDs used pediatric telehealth services infrequently. Understanding barriers to assimilation of telehealth once adopted may be important to enable improved access to pediatric emergency care expertise.

Prevalence of social risk factors and social needs in a Medicaid Accountable Care Organization (ACO).

BACKGROUND: Health-related social needs (HRSN) are associated with higher chronic disease prevalence and healthcare utilization. Health systems increasingly screen for HRSN during routine care. In this study, we compare the differential prevalence of social risk factors and social needs in a Medicaid Accountable Care Organization (ACO) and identify the patient and practice characteristics associated with reporting social needs in a different domain from social risks. METHODS: Cross-sectional study of patient responses to HRSN screening February 2019-February 2020. HRSN screening occurred as part of routine primary care and assessed social risk factors in eight domains and social needs by requesting resources in these domains. Participants included adult and pediatric patients from 114 primary care practices. We measured patient-reported social risk factors and social needs from the HRSN screening, and performed multivariable regression to evaluate patient and practice characteristics associated with reporting social needs and concordance to social risks. Covariates included patient age, sex, race, ethnicity, language, and practice proportion of patients with Medicaid and/or Limited English Proficiency (LEP). RESULTS: Twenty-seven thousand four hundred thirteen individuals completed 30,703 screenings, including 15,205 (55.5%) caregivers of pediatric patients. Among completed screenings, 13,692 (44.6%) were positive for ≥ 1 social risk factor and 2,944 (9.6%) for ≥ 3 risks; 5,861 (19.1%) were positive for social needs and 4,848 (35.4%) for both. Notably, 1,013 (6.0%) were negative for social risks but positive for social needs. Patients who did not identify as non-Hispanic White or were in higher proportion LEP or Medicaid practices were more likely to report social needs, with or without social risks. Patients who were non-Hispanic Black, Hispanic, preferred non-English languages or were in higher LEP or Medicaid practices were more likely to report social needs without accompanying social risks. CONCLUSIONS: Half of Medicaid ACO patients screened for HRSN reported social risk factors or social needs, with incomplete overlap between groups. Screening for both social risks and social needs can identify more individuals with HRSN and increase opportunities to mitigate negative health outcomes.

Emergency Departments' Uptake of Telehealth for Stroke Versus Pediatric Care: Observational Study.

BACKGROUND: Telehealth for emergency stroke care delivery (telestroke) has had widespread adoption, enabling many hospitals to obtain stroke center certification. Telehealth for pediatric emergency care has been less widely adopted. OBJECTIVE: Our primary objective was to determine whether differences in policy or certification requirements contributed to differential uptake of telestroke versus pediatric telehealth. We hypothesized that differences in financial incentives, based on differences in patient volume, prehospital routing policy, and certification requirements, contributed to differential emergency department (ED) adoption of telestroke versus pediatric telehealth. METHODS: We used the 2016 National Emergency Department Inventory-USA to identify EDs that were using telestroke and pediatric telehealth services. We surveyed all EDs using pediatric telehealth services (n=339) and a convenience sample of the 1758 EDs with telestroke services (n=366). The surveys characterized ED staffing, transfer patterns, reasons for adoption, and frequency of use. We used bivariate comparisons to examine differences in reasons for adoption and use between EDs with only telestroke services, only pediatric telehealth services, or both. RESULTS: Of the 442 EDs surveyed, 378 (85.5%) indicated use of telestroke, pediatric telehealth, or both. EDs with both services were smaller in bed size, volume, and ED attending coverage than those with only telestroke services or only pediatric telehealth services. EDs with telestroke services reported more frequent use, overall, than EDs with pediatric telehealth services: 14.1% (45/320) of EDs with telestroke services reported weekly use versus 2.9% (8/272) of EDs with pediatric telehealth services (P<.001). In addition, 37 out of 272 (13.6%) EDs with pediatric telehealth services reported no consults in the past year. Across applications, the most frequently selected reason for adoption was "improving level of clinical care." Policy-related reasons (ie, for compliance with outside certification or standards or for improving ED performance on quality metrics) were rarely indicated as the most important, but these reasons were indicated slightly more often for telestroke adoption (12/320, 3.8%) than for pediatric telehealth adoption (1/272, 0.4%; P=.003). CONCLUSIONS: In 2016, more US EDs had telestroke services than pediatric telehealth services; among EDs with the technology, consults were more frequently made for stroke than for pediatric patients. The most frequently indicated reason for adoption among all EDs was related to clinical care.

A Multistate Survey of Pediatric Emergency Care Coordinator Activities.

BACKGROUND: Pediatric emergency care coordinators (PECCs) are associated with pediatric readiness of emergency departments (EDs). National organizations have called for PECCs in all EDs. Although the National Pediatric Readiness Program provides a list of suggested tasks for each PECC, little is known about implementation. Our objective was to describe the role of PECCs in EDs. METHODS: We analyzed data from the 2019 National ED Inventory-USA to identify EDs with PECCs in 8 states (Arkansas, Florida, Iowa, Maryland, Nebraska, New York, Vermont, and Wisconsin). We called each ED that reported having a PECC to administer a standardized survey assessing NRPP tasks, specifically quality improvement (QI), education provision, skill verification, equipment responsibilities, and how many hours the PECC devoted to the role. RESULTS: Of the 201 of 830 EDs (24%) that reported a PECC, 167 (83%) completed the survey, with >80% response rate in each state. Of these, 153 EDs (92%) confirmed a PECC, and during the past year, 81% participated in QI initiatives, 93% provided pediatric education, 90% verified staff skills, and 90% were responsible for ensuring medications, equipment, supplies, and resources for children. The median number of hours per week that PECCs devoted to this role was 12 (interquartile range, 5-40). There was wide variation between states (eg, 50% of PECCs in Vermont participating in QI activities, as compared with 100% in Nebraska). CONCLUSIONS: Most PECCs report participating in the suggested National Pediatric Readiness Program tasks, although there was variation by state. Future directions for this work include assessing the association between PECC tasks and patient outcomes.

Acute Care Utilization and Health Care Expenditures in Medicaid-Enrolled Children.

OBJECTIVES: Although recent health care reform efforts have focused on minimizing high cost health care utilization, the relationship between acute care use and health care expenditures among certain vulnerable populations such as Medicaid-insured children remains poorly understood. We sought to evaluate the association between acute care utilization and health care expenditures and to identify characteristics associated with high spending. METHODS: We performed a retrospective cohort study of Medicaid-enrolled children 1-21 years old from 1/1/2016 to 12/31/2016. Children were categorized by acute care use (including emergency department and urgent care visits) as 0, 1, 2, 3, and 4 or more visits. Our main outcomes were annualized spending, total per-member-per-year spending, and acute care-related per-member-per-year spending. RESULTS: There were 5.1 million Medicaid-enrolled children that comprised the study cohort, accounting for US $32.6 billion in total spending. Children with 4 or more acute care visits were more likely to be younger than 2 years or older than 14 years, female, and have a chronic condition. Children with 4 or more acute care visits consisted of only 4% of the cohort but accounted for 15% (US $4.7 billion) of the total spending. Increasing acute care visits were associated with increasing total annualized spending in adjusted analyses (P < 0.001). This association was disproportionately observed in older age groups and children without chronic medical conditions. CONCLUSIONS: Medicaid spending for children increases with increasing acute care use; this trend was disproportionately observed in older age groups and children without chronic medical conditions. Improved understanding of factors contributing to frequent acute care utilization and disproportionate spending is needed to potentially reduce unnecessary health care costs in these pediatric populations.

Availability of Pediatric Emergency Care Coordinators in United States Emergency Departments.

OBJECTIVE: To determine the availability of pediatric emergency care coordinators (PECCs) in US emergency departments (EDs) in 2015, and to determine the change in availability of PECCs in US EDs from 2015 to 2017. STUDY DESIGN: As part of the National Emergency Department Inventory-USA, we administered a survey to all 5326 US EDs open in 2015; all 5431 in 2016; and all 5489 in 2017. Through these surveys, we assessed the availability of PECCs. Descriptive statistics characterized EDs with and without PECCs; multivariable logistic regressions identified characteristics independently associated with PECC availability. RESULTS: Among the 4443 (83%) EDs with 2015 data, 763 (17.2%) reported the availability of at least 1 PECC. The states with the largest proportion of EDs with PECCs were Delaware (78%, 7/9 EDs) and Maryland (48%, 20/42 EDs), and no PECCs were reported in Mississippi, North Dakota, or Wyoming. Availability of a PECC was associated (P < .001) with larger annual total ED visit volume and a dedicated pediatric ED area. Compared with the 17.2% of EDs reporting a PECC in 2015, 833 (18.6%) reported 1 in 2016, and 917 (19.8%) reported 1 in 2017 (P < .001). CONCLUSIONS: Availability of at least 1 PECC increased slightly (2.6%) between 2015 and 2017, but ∼80% of EDs continue without one.

Screening for Health-Related Social Needs of Emergency Department Patients.

STUDY OBJECTIVE: There has been increasing attention to screening for health-related social needs. However, little is known about the screening practices of emergency departments (EDs). Within New England, we seek to identify the prevalence of ED screening for health-related social needs, understand the factors associated with screening, and understand how screening patterns for health-related social needs differ from those for violence, substance use, and mental health needs. METHODS: We analyzed data from the 2018 National Emergency Department Inventory-New England survey, which was administered to all 194 New England EDs during 2019. We used descriptive statistics to compare ED characteristics by screening practices, and multivariable logistic regression models to identify factors associated with screening. RESULTS: Among the 166 (86%) responding EDs, 64 (39%) reported screening for at least one health-related social need, 160 (96%) for violence (including intimate partner violence or other violent exposures), 148 (89%) for substance use disorder, and 159 (96%) for mental health needs. EDs reported a wide range of social work resources to address identified needs, with 155 (93%) reporting any social worker availability and 41 (27%) reporting continuous availability. CONCLUSION: New England EDs are screening for health-related social needs at a markedly lower rate than for violence, substance use, and mental health needs. EDs have relatively limited resources available to address health-related social needs. We encourage research on the development of scalable solutions for identifying and addressing health-related social needs in the ED.

Comparing neighborhood-based indices of socioeconomic risk factors and potentially preventable emergency department utilization.

BACKGROUND: Neighborhood stress score (NSS) and area deprivation index (ADI) are two neighborhood-based composite measures used to quantify an individual's socioeconomic risk based on home location. In this analysis, we compare the relationships between an individual's socioeconomic risk, based on each of these measures, and potentially preventable acute care utilization. METHODS: Using emergency department (ED) visit data from two academic medical centers in Boston, Massachusetts, we conducted adjusted Poisson regressions of ADI decile and NSS decile with counts of low acuity ED visits, admissions for ambulatory care sensitive conditions (ACSCs), and patients with high frequency ED utilization at the census block group (CBG) level within the greater Boston area. RESULTS: Both NSS and ADI decile were associated with elevated rates of utilization, although the associated incidence rate ratios (IRRs) for NSS were higher than those for ADI across all three measures. NSS decile was associated with IRRs of 1.11 [95% CI: 1.10-1.12], 1.16 [1.14-1.17], and 1.22 [1.19-1.25] for ACSC admissions, low acuity ED visits, and patients with high frequency ED utilization, respectively; compared with 1.04 [1.04-1.05], 1.11 [1.10-1.11], and 1.10 [1.08-1.12] for ADI decile. CONCLUSION: ADI and NSS both represent effective tools to assess the potential impact of geographically-linked socioeconomic drivers of health on potentially preventable acute care utilization. NSS decile was associated with a greater effect size for each measure of utilization suggesting that this may be a stronger predictor, however, additional research is necessary to evaluate these findings in other contexts.

A Predictive Model for Identification of Children at Risk of Subsequent High-Frequency Utilization of the Emergency Department for Asthma.

BACKGROUND: Asthma is the most common chronic condition among children with high-frequency emergency department (ED) utilization. Previous research has shown in outpatients seen for asthma that acute care visits predict subsequent health care utilization. Among ED patients, however, the optimal method of predicting subsequent ED utilization remains to be described. The goal of this study was to create a predictive model to identify children in the ED who are at risk of subsequent high-frequency utilization of the ED for asthma. METHODS: We used 3 years of data, 2013-2015, drawn from the electronic health records at a tertiary care, urban, children's hospital that is a high-volume center for asthma care. Data were split into a derivation (50%) and validation/test (50%) set, and 3 models were created for testing: (1) all index patients; (2) removing patients with complex chronic conditions; and (3) subset of patients with in-network care on whom more clinical data were available. Each multivariable model was then tested in the validation set, and its performance evaluated by predicting error rate, calculation of a receiver operating characteristic (ROC) curve, and identification of the optimal cutpoint to maximize sensitivity and specificity. RESULTS: There were 5535 patients with index ED visits, of whom 2767 were in the derivation set and 2768 in the validation set. Of the 5535 patients, 125 patients (2.3%) had 4 or more visits for asthma in the outcome year. Significant predictors in models 1 and 2 were age and number of prior ED visits for asthma. For model 3 (additional clinical information available), the predictors were number of prior ED visits for asthma, number of primary care visits, and not having a controller medication. Areas under the ROC curve were 0.77 for model 1, 0.80 for model 2, and 0.77 for model 3. CONCLUSIONS: Administrative data available at the time of ED triage can predict subsequent high utilization of the ED, with areas under the ROC curve of 0.77 to 0.80. The addition of clinical variables did not improve the model performance. These models provide useful tools for researchers interested in examining intervention efficacy by predicted risk group.

Man with hand pain.

CLINICAL INTRODUCTION: A right-hand dominant man was transferred to our institution for evaluation by the hand surgery service. He reported that the day prior he had been sliding a sheet of plywood across the ground when he lost his grip, causing the board to slide across his left hand. He presented to an outside hospital where local exploration of the wound did not reveal any foreign body. On arrival, he complained only of mild pain in his hand. Physical examination revealed erythema and swelling over the thenar eminence and a small open area without any drainage. Radiographs (figure 1) and ultrasonography (figures 2 and 3, online supplementary video 1 and 2) were performed.DC1SP110.1136/emermed-2018-207679.supp1Supplementary dataemermed;35/12/731/F1F1F1Figure 1Radiograph of the hand.emermed;35/12/731/F2F2F2Figure 2Long-axis ultrasonography of the hand.emermed;35/12/731/F3F3F3Figure 3Short-axis ultrasonography of the hand. QUESTION: What is you diagnosis?Fracture of the metacarpal of the thumb.Cellulitis of the thenar eminence.Abscess of the thenar eminence.Retained foreign body.

Comparing resource use between paediatric emergency department visits by triage level.

OBJECTIVE: The majority of paediatric ED visits result in discharge but little is known about what ED resources are deployed for these visits. The goal of this study was to understand the utilisation of diagnostic testing, procedures and hospital admission for paediatric ED visits triaged as 'non-urgent'. STUDY DESIGN: We examined US ED visits for children aged 0-17 years from 1 January 2009 to 31 December 2011 in the National Hospital Ambulatory Medical Care Survey. Visits triaged on arrival as 'non-urgent' (level 5) were compared with urgent visits (triage levels 1-4) for resource use and disposition. Sensitivity and specificity of triage for predicting resource use and disposition were assessed. RESULTS: Among 21 052 observations, representing 86 620 988 visits, 11.1% were triaged as 'non-urgent'. Diagnostic services were provided during 37.6% (95% CI 33.9% to 41.4%) of non-urgent and 55.2% (95% CI 53.3% to 57.2%) of urgent visits. Procedures were performed in 23.9% (95% CI 20.4% to 27.3%) of non-urgent and 33.9% (95% CI 31.2% to 35.9%) of urgent visits. 1.7% (95% CI 0.09% to 2.6%) of the non-urgent visits resulted in admission, with 0.08% (95% CI 0% to 0.2%) to critical care units, compared with 4.4% (95% CI 3.6% to 5.2%) of the urgent visits, with 0.3% (95% CI 0.2% to 0.4%) to critical care. Despite some substantial differences in the rates of resource use, triage score had poor sensitivity for identifying patients who did not receive ED tests, procedures or admission. CONCLUSION: A significant percentage of ED patients with non-urgent ED triage scores received ED testing and procedures. More work is needed to improve methods of prospectively identifying patients with low acuity complaints who do not need significant ED resources.