Change of address as a measure of housing insecurity predicting rural emergency department revisits after asthma exacerbation.

OBJECTIVE: Housing insecurity is an important socioeconomic factor that may impact emergency department (ED) use for children with asthma, but housing insecurity screening has primarily relied on patient surveys or linkage to external data sources. Using patient addresses recorded in the electronic medical record (EMR), we sought to correlate recent changes in address (as a proxy for housing insecurity) with ED revisit risk. METHODS: We retrospectively identified patients age 2-17 years seen in our rural ED for asthma exacerbation during 2016-2018. We used EMR data from the 12 months before the earliest ED visit to compare patients with and without a recent change of address (over previous 12 months) on 30- and 90-day all-cause and asthma-specific ED revisits. RESULTS: The study included 632 children, of whom 85 (13%) had a recent address change before the index ED visit. Moving was not associated with asthma-specific 30-day or 90-day revisits. Ninety-day all-cause revisits were more common among patients who had recently moved (36% vs. 25%; p = 0.019), although this difference was not statistically significant after multivariable adjustment for Medicaid insurance coverage and number of recent health system encounters (odds ratio: 1.49; 95% confidence interval: 0.91, 2.46; p = 0.114). CONCLUSIONS: A history of recent address change in the EMR was not independently associated with repeat ED visits for asthma exacerbation. Many children presenting to the ED did not have recent encounters with our health system where address could be ascertained. This EMR-based proxy for housing insecurity may be more applicable to patients under continuous follow-up.

Communication Between Primary Care Pediatricians and the Pediatric Emergency Department.

OBJECTIVES: This study aimed to measure the quality of communication from primary care pediatricians (PCPs) to the pediatric emergency department (ED). We also sought to determine whether the quality of this communication affected patient outcomes. METHODS: We conducted a retrospective chart review of patients sent from their pediatrician to the pediatric ED during a 4-year period. The quality of communication was classified as no communication, incomplete communication, or complete communication, based on compliance with Joint Commission requirements. Outcome measures included overnight admission, total length of hospital stay, repetition of diagnostic tests, ED revisits, hospital readmissions, and initial follow-up pediatrician visit. RESULTS: Fifty-five patients were included in the analysis. Communication was complete in 22% of cases, incomplete in 16% of cases, and absent in 62% of cases. Medications and allergies were most often missing. The quality of communication was not associated with any of the prespecified covariates or outcome measures. Chief complaint of respiratory distress and greater severity score were associated with a greater likelihood of hospital admission from the ED. CONCLUSIONS: Our study demonstrates a lack of documented communication between PCPs and a pediatric ED, albeit with no statistically significant impact on patient outcomes. Practices to increase the quality of PCP-ED communication could include standardizing interfacility referrals, maximizing shared electronic health record use between clinical environments, and increased collaboration between ED physicians and PCPs. Further research to investigate subjective outcomes, such as patient expectations or satisfaction associated with PCP-ED communication, may reveal other consequences of incomplete communication.

Sports-Related Concussions in Children: Differences in Care and Expectations When Seen in an Emergency Department Versus a Sports Medicine Clinic.

OBJECTIVES: Patient and parent expectations can potentially influence management of care. We compared expectations in the diagnosis of concussion between patients who presented to a pediatric emergency department (ED) and those who presented to a sports medicine clinic, and if there was a difference in computed tomography (CT) scans performed. METHODS: Head-injured athletes aged 8 to 18 years presenting to a pediatric ED and a sports medicine clinic were enrolled. Both groups completed questionnaires on their understanding of concussion and expectations of care. Charts were then reviewed. RESULTS: Forty patients were enrolled in the study: 23 from a pediatric ED and 17 from a sports medicine clinic. Forty-one percent of athletes received a head CT in the pediatric ED versus 12% of those in the clinic population with no abnormal findings (P = 0.04). Forty-one percent of athletes and 48% of parents in the pediatric ED setting reported that a CT was "necessary" to diagnose concussion versus 18% in both groups from the clinic (P = 0.12, P = 0.07). Athletes presenting to the clinic were more likely to have been evaluated by an athletic trainer after the injury than those presenting to the pediatric ED (80% vs 23%, P = 0.004). CONCLUSIONS: Patients and parents who presented to a pediatric ED for sports-related head injury had a trend toward higher expectations of a CT scan being necessary to diagnose concussion and did have a higher rate of CT scans performed. Education of athletes and parents engaging in organized sports may be worthwhile to assist in setting expectations in diagnosis of concussion.