The Impact of Diagnostic Decisions on Patient Experience in the Pediatric Emergency Department.

OBJECTIVE: Patient experience serves as both a subjective measure of value-based health care delivery and a metric to inform operational decision making. The objective of this study was to determine if specific diagnostic and therapeutic interventions affect patient experience scores for children seen in the emergency department. METHODS: We performed a retrospective observational study in the emergency department of a large quaternary care children's hospital on patients who were discharged to home and later completed a National Research Corporation Health patient experience survey. We matched the survey results to electronic health record (EHR) data and were able to extract demographics, operational metrics, and order information for each patient. We performed multiple logistic regression analyses to determine the association of image acquisition, laboratory test ordering, medication administration, and discharge prescribing with likelihood to recommend the facility as our measure of patient experience. RESULTS: Of the 4103 patients who met inclusion criteria for the study, 75% strongly recommended the facility. Longer wait times were associated with lower patient experience scores [odds ratio (OR) per waiting room hour increase, 0.72; 95% confidence interval (CI), 0.65-0.81]. Significant diagnostic factors associated with higher patient experience included magnetic resonance imaging ordering (OR, 2.38; 95% CI, 1.00-5.67), x-ray ordering (OR, 1.19; 95% CI, 1.00-1.42), and electrocardiogram ordering (OR, 1.62; 95% CI, 1.07-2.44). Of the treatment factors studied, only antibiotic prescribing at discharge was found to have a significant positive association with patient experience (OR, 1.32; 95% CI, 1.08-1.63). CONCLUSION: The positive association between more intensive diagnostic workups and patient experience could have implications on the utility of patient experience scores to evaluate pediatric care teams. Consideration should be taken to interpret patient experience scores in the context of compliance with approaches in evidence-based medicine.

Crowding is the strongest predictor of left without being seen risk in a pediatric emergency department.

BACKGROUND: Emergency Department (ED) patients who leave without being seen (LWBS) are associated with adverse safety and medico-legal consequences. While LWBS risk has been previously tied to demographic and acuity related factors, there is limited research examining crowding-related risk in the pediatric setting. The primary objective of this study was to determine the association between LWBS risk and crowding, using the National Emergency Department Overcrowding Score (NEDOCS) and occupancy rate as crowding metrics. METHODS: We performed a retrospective observational study on electronic health record (EHR) data from the ED of a quaternary care children's hospital and trauma center during the 14-month study period. NEDOCS and occupancy rate were calculated for 15-min windows and matched to patient arrival time. We leveraged multiple logistic regression analyses to demonstrate the relationship between patientlevel LWBS risk and each crowding metric, controlling for characteristics drawn from the pre-arrival state. We performed a chi-squared test to determine whether a difference existed between the receiver operating characteristic (ROC) curves in the two models. Finally, we executed a dominance analysis using McFadden's pseudo-R 2 to determine the relative importance of each crowding metric in the models. RESULTS: A total of 54,890 patient encounters were studied, 1.22% of whom LWBS. The odds ratio for LWBS risk was 1.30 (95% CI 1.27-1.33) per 10-point increase in NEDOCS and 1.23 (95% CI 1.21-1.25). per 10% increase in occupancy rate. Area under the curve (AUC) was 86.9% for the NEDOCS model and 86.7% for the occupancy rate model. There was no statistically significant difference between the AUCs of the two models (p-value 0.27). Dominance analysis revealed that in each model, the most important variable studied was its respective crowding metric; NEDOCS accounted for 55.6% and occupancy rate accounted for 53.9% of predicted variance in LWBS. CONCLUSION: Not only was ED overcrowding positively and significantly associated with individual LWBS risk, but it was the single most important factor that determined a patient's likelihood of LWBS in the pediatric ED. Because occupancy rate and NEDOCS are available in real time, each could serve as a monitor for individual LWBS risk in the pediatric ED.

Gastrostomy tube replacement in a pediatric ED: frequency of complications and impact of confirmatory imaging.

BACKGROUND: Gastrostomy tube (g-tube) dislodgement is a common problem in special needs children. There are no studies on the frequency of complications after g-tube replacement for children in a pediatric emergency department (ED). OBJECTIVES: The objective of this study is to determine the frequency of misplacement and subsequent complications for children undergoing g-tube replacement in a pediatric ED and the impact of contrast-enhanced confirmatory imaging on ED length of stay (LOS). METHODS: This was a retrospective review of children presenting to a pediatric ED over 16 months. Subjects were included if they underwent g-tube replacement in the ED. Records were reviewed for historical and procedural data including patient age, g-tube age, ED LOS, documented difficulties replacing the tube, performance of confirmatory imaging (contrast-enhanced radiograph), and complications identified within 72 hours of ED visit. RESULTS: A total of 237 children met inclusion criteria. Three (1.2%) had evidence of g-tube misplacement, all of whom underwent confirmatory imaging. One complication from misplacement was identified (gastric outlet obstruction from overfilled balloon). Tract disruption was not identified for any subject. Eighty-four subjects (35%) had confirmatory imaging performed after replacement. Mean ED LOS in the imaged group was 265 vs 142 minutes for the nonimaged group (P < .001). No subjects with documentation of clinical confirmation had subsequent evidence of misplacement. CONCLUSIONS: For children undergoing g-tube replacement in a pediatric ED, misplacement and associated complications were rare. Confirmatory imaging was associated with a considerably longer LOS. In the presence of clinical confirmation, confirmatory imaging may be judiciously used.