Before the Flood: Impact of Coordination of Care and Direct Admissions on Emergency Department Volumes.

BACKGROUND: Transfers of pediatric patients occur to access specialty and subspecialty care, but incur risk, and consume resources. Direct admissions to medical and surgical wards may improve patient experience and mitigate resource utilization. OBJECTIVE: We sought to identify common elements for direct admissions, as well as the pattern of disposition for patients referred to our emergency department (ED). DESIGN: A retrospective qualitative analysis of patients transferred to our pediatric hospital for 12 months was performed. Different physician groups were evaluated for use of direct admissions or evaluation in the ED. Patients referred to the ED were additionally tracked to evaluate their eventual disposition. RESULTS: A total of 3982 transfers occurred during the 12-month analysis period. Of those, 3463 resulted in admission, accounting for 32.55% of all admissions. Transfers accepted by nonsurgical services accounted for 82% of the transfers, whereas 18% were facilitated by one of the surgical services. Direct admissions accounted for 1707 (44.8%) of all referrals and were used more often by nonsurgical services. Of patients referred to the ED (2101 or 55.2% of all referrals), most patients were admitted and 343 (16% of those referred to the ED) were discharged home. CONCLUSIONS: The direct admission process helped avoid ED assessments for some patients; however, some patients referred to the ED were able to be evaluated, treated, and discharged. Consistent triage of the patients being transferred as direct admissions may improve ED throughput and potentially improve the patient's experience, reduce redundant services, and expedite care.

Descriptive Correlates of Urban Pediatric Violent Injury Using Emergency Medical Service Patient-Level Data.

OBJECTIVE: This study aimed to describe spatiotemporal correlates of pediatric violent injury in an urban community. METHODS: We performed a retrospective cohort study using patient-level data (2009-2011) from a novel emergency medical service computerized entry system for violent injury resulting in an ambulance dispatch among children aged 0 to 16 years. Assault location and patient residence location were cleaned and geocoded at a success rate of 98%. Distances from the assault location to both home and nearest school were calculated. Time and day of injury were used to evaluate temporal trends. Data from the event points were analyzed to locate injury "hotspots." RESULTS: Seventy-six percent of events occurred within 2 blocks of the patient's home. Clusters of violent injury correlated with areas with high adult crime and areas with multiple schools. More than half of the events occurred between 3:00 PM and 11:00 PM. During these peak hours, Sundays had significantly fewer events. CONCLUSIONS: Pediatric violent injuries occurred in identifiable geographic and temporal patterns. This has implications for injury prevention programming to prioritize highest-risk areas.

Emergency department transport rates of children from the scene of motor vehicle collisions: do booster seats make a difference?

BACKGROUND: Motor vehicle collisions (MVCs) are the leading cause of death and disability among children older than 1 year. Many states currently mandate all children between the ages of 4 and 8 years be restrained in booster seats. The implementation of a booster-seat law is generally thought to decrease the occurrence of injury to children. We hypothesized that appropriate restraint with booster seats would also cause a decrease in emergency department (ED) visits compared with children who were unrestrained. This is an important measure as ED visits are a surrogate marker for injury. OBJECTIVE: The main purpose of this study was to look at the rate of ED visits between children in booster seats compared with those in other or no restraint systems involved in MVCs. Injury severity was compared across restraint types as a secondary outcome of booster-seat use after the implementation of a state law. METHODS: A prospective observational study was performed including all children 4 to 8 years old involved in MVCs to which emergency medical services was dispatched. Ambulance services used a novel on-scene computer charting system for all MVC-related encounters to collect age, sex, child-restraint system, Glasgow Coma Scale score, injuries, and final disposition. RESULTS: One hundred fifty-nine children were studied with 58 children (35.6%) in booster seats, 73 children in seatbelts alone (45.2%), and 28 children (19.1%) in no restraint system. 76 children (47.7%), 74 by emergency medical services and 2 by private vehicle, were transported to the ED with no significant difference between restraint use (P = 0.534). Utilization of a restraint system did not significantly impact MVC injury severity. However, of those children who either died (n = 2) or had an on-scene decreased Glasgow Coma Scale score (n = 6), 75% (6/8) were not restrained in a booster seat. CONCLUSIONS: The use of booster-seat restraints does not appear to be associated with whether a child will be transported to the ED for trauma evaluation.

Patient Protection and Affordable Care Act of 2010: summary, analysis, and opportunities for advocacy for the academic emergency physician.

The Patient Protection and Affordable Care Bill, commonly referred to as the "Health Care Bill" or the "Health Care Reform Bill," was enacted in March 2010. This article is a review and analysis of the sections of this Act that are relevant to researchers and teachers of emergency care. The purpose of this document is to serve as a citable reference for interested parties and a reference to quickly locate the sections of the Bill relevant to academic emergency physicians. When appropriate, text was copied verbatim from the Bill. The source of the downloaded Act, and the page numbers of the text sections, are provided to help the reader to find the sections described. This review is presented in two parts. Part I presents 11 sections extirpated from the Act, with short interpretations of the significance of each section. Part II presents an analysis of the sections that the authors believe represent opportunities for emergency care researchers and teachers to make the most impact, through active involvement with the various departments and agencies of the federal government that will be charged with interpreting and implementing this Act. The Act contains sections that could lead to new funding opportunities for research in emergency care, especially for comparative clinical trials and clinical studies that focus on integration and efficiency of health care delivery. The Act will establish several new institutes, centers, and committees that will create policies highly relevant to emergency care. The authors conclude that this Act can be expected to have a profound influence on research and training in emergency care.

Best educational practices in pediatric emergency medicine during emergency medicine residency training: guiding principles and expert recommendations.

The state of pediatric emergency medicine (PEM) education within emergency medicine (EM) residency programs is reviewed and discussed in the context of shifting practice environments and new demands for a greater focus on the availability and quality of PEM services. The rapid growth of PEM within pediatrics has altered the EM practice landscape with regard to PEM. The authors evaluate the composition, quantity, and quality of PEM training in EM residency programs, with close attention paid to the challenges facing programs. A set of best practices is presented as a framework for discussion of future PEM training that would increase the yield and relevance of knowledge and experiences within the constraints of 3- and 4-year residencies. Innovative educational modalities are discussed, as well as the role of simulation and pediatric-specific patient safety education. Finally, barriers to PEM fellowship training among EM residency graduates are discussed in light of the shortage of practitioners from this training pathway and in recognition of the ongoing importance of the EM voice in PEM.