Adults Followed by Pediatric Subspecialists: A Growing Population in the Pediatric Emergency Department.

BACKGROUND: Adults are being seen with increasing frequency in pediatric emergency departments (PEDs), but the drivers behind this increase are unknown. Our primary aim was to compare adults seen in the PED followed by pediatric subspecialists to those who are not. METHODS: A retrospective study of patients 21 years or older presenting to the PED of a tertiary care children's hospital was performed from January 2011 through December 2018. Data included patient demographics, PED length of stay, disposition, and any subspecialty clinic encounters at the children's hospital in the prior year. RESULTS: A total of 10,034 adult encounters were seen in the PED over the study period; 5852 (58.3%) adult PED encounters had preceding pediatric subspecialty clinic visit(s) within a year prior. Pediatric subspecialty adult PED encounters increased by 38.9%, compared with 10.6% for other adults (P = 0.01). Encounters for pediatric subspecialty adults were significantly longer and more likely to result in admission to the children's hospital. The most common pediatric subspecialists caring for adult patients seen in the PED were hematology/oncology (1655 encounters), neurology (1572 encounters), cardiology (1217 encounters), and gastroenterology (1173 encounters). CONCLUSIONS: Pediatric subspecialty adults are presenting to the PED at a greater rate, and they require more time and resources compared with other presenting adults. As frontline providers, PEDs, physicians, and staff must be prepared to address this growing subset of patients driving the increase in adults presenting to the PED.

Pilot of primary care physician discussion and resource allocation after screening for unintentional injuries and social determinants of health.

BACKGROUND: Standardized screening tools used by pediatric providers can help determine a child's injury and social risks. This study determined if an office-based quality improvement program could increase targeted anticipatory guidance and community resource distribution to families. METHODS: Practices recruited from the Ohio Chapter, American Academy of Pediatrics' database self-selected to participate in a quality improvement project. Two age-appropriate screening tools, corresponding talking points and local resources for birth-1 year and 1-5 year aged children were developed for unintentional injury and social health determinant topics. After a one-day learning session, practice teams implemented the tools into well-child care visits for children < 5 years of age. Two months of retrospective baseline data was collected for each participating clinician. During the 6-month collaborative, physicians randomly reviewed 5 screening tools monthly for each age category to identify injury and social risk discussions and to determine if resources were provided. Frequencies of counseling and resource distribution were calculated. Participating providers received Maintenance of Certification IV credit. RESULTS: Ten practices (18 providers) participated and 667 tools (n = 313, birth-1 year, n = 354, 1-5 year) were collected. For birth-1 year, the most common risky behaviors were related to unintentional injuries: no CPR training 164(52%), car seat not checked 149(48%) and home furniture not secured 117 (37%). For 1-5 year screens, unintentional injuries were also most common: no CPR training 222(63%), car seat not checked 203(57%) and access to choking hazards 198(56%). Families practiced riskier behaviors for unintentional injuries compared to social risks for both age groups (birth - 1 year, social 189/4801 (4%) vs. unintentional injury questions 999/6260 (16%) and 1-5 years, social 271/5451 (5%) vs unintentional injury questions 1140/6372 (18%). From baseline, discussions increased from 31% to 83% for birth - 1 year and 24% to 86% for 1-5 year families. Resource distribution increased by 63% for birth-1 year and 69% for 1-5 year families by pilot conclusion. CONCLUSIONS: Using standardized screening tools in an office setting shows that families often practice unintentional injury risks more than having social concerns. After screening, appropriate resources can be provided to families to encourage behavior change.

ED utilization trends in sports-related traumatic brain injury.

BACKGROUND: Emergency department (ED) visits for sports-related traumatic brain injuries (TBIs) have risen. This study evaluated how the number and severity of admissions have changed as ED visits for sports-related TBIs have increased. METHODS: A retrospective study of children aged 0 to 19 years at a level 1 trauma center was performed. Patients from 2002 to 2011 with a primary or secondary diagnosis of TBI were identified from the hospital's inpatient and outpatient trauma registries. Frequencies were used to characterize the population, χ(2) analysis was performed to determine differences between groups, and regression analysis looked at relationship between year and injury severity score or length of stay. RESULTS: Sport was responsible for injury in 3878 (15.4%) cases during the study period; 3506 (90.4%) were discharged from the hospital, and 372 (9.6%) were admitted. Seventy-three percent were male patients and 78% Caucasian; mean age was 13 ± 3.5 years. ED visits for sports-related TBIs increased 92% over the study period, yet there was no significant change (χ(2) = 9.8, df = 9, P = .37) in the percentage of children admitted. Mean injury severity score for those admitted decreased from 7.8 to 4.8 (ß = -0.46; P = .006); length of stay trended downward (ß = -0.05; P = .05). CONCLUSIONS: The percentage of children being admitted from the ED with sports-related TBI has not changed over the past 10 years. The severity of admitted sports-related TBI is decreasing. Additional research is needed to correlate these trends with other TBI mechanisms.

Is spontaneous pneumothorax really a pediatric problem? A national perspective.

OBJECTIVES: Research on spontaneous pneumothorax (SP) has focused on management strategies in adolescents and adults, yet pediatric population-based data are lacking. The objective of this study was to determine the incidence of SP in the pediatric population in different age groups. METHODS: This was a retrospective analysis of patients aged 0 to 17 years hospitalized with a diagnosis of SP from the Healthcare Cost and Utilization Project Kids' Inpatient Database between 1997 and 2006. Trends of overall incidence and demographic information, including age, sex, length of stay, associated procedures, and associated conditions, were obtained and analyzed. RESULTS: The overall incidence of SP in children younger than 18 years increased from 2.68 per 100,000 population in 1997 to 3.41 per 100,000 in 2006. Average age (15.1 years; SE, 0.1 years), age distribution (83% = 15-17 years old), and hospital length of stay (4.7 days; SE, 0.1 days) remained constant. Between 1997 and 2006, males rose from 3.7 times to 4.2 times as likely to develop SP as females. In 2006, 70% of all hospitalized SP patients had therapeutic procedures documented: chest tube (32%), bleb excision (20%), and thoracotomy (8%) were the most common. Emphysematous bleb (21%), asthma (10%), and tobacco use (4%) were the most common associated diagnoses in 2006. CONCLUSIONS: Although uncommon in children, SP appears to be primarily a condition of males and adolescents and appears to be increasing in incidence in this population. According to these data, a large portion of children are being managed without procedural intervention.

Prevalence and trends of the adult patient population in a pediatric emergency department.

OBJECTIVES: Although pediatric emergency departments (PEDs) generally do not care for adult patients (≥21 years old), adult patients still present to PEDs with short-term complaints. The purpose of this study was to describe trends in the prevalence, the acuity, and the causes of adult patients presenting to a PED. METHODS: Patients consisted of adults (≥21 years old) seen in a large, urban PED from January 1, 2004, to December 31, 2008. Data were obtained retrospectively from the electronic medical record. Data included demographics, triage acuity, primary codes according to the International Classification of Diseases, 9th Revision, insurance status, referred status, and disposition. RESULTS: There were 463,827 patient visits during the study period. Of these visits, 3361 (0.7%) were adult patients, with a mean (SD) age of 27.5 (9) years. During the 5-year study period, overall PED visits increased by 9% (from 85,987 to 93,753), whereas adult patient visits increased 29% (from 605 to 780). Of the adult patients seen, 1898 (55%) were white and 2100 (62%) were female. Moreover, 1465 (44%) were triaged either emergently or to the medical/trauma resuscitation room, 652 (20%) were admitted, and 677 (20%) were transferred to another facility. Of these adult patients, 712 (21%) were referred to our PED by a primary care provider or subspecialist, and 790 (29%) had no insurance. CONCLUSIONS: Adult visits to a large, urban PED have increased significantly during the past 5 years. Often, these patients have little or no insurance and present with a high acuity. Transitioning adult patients with long-term "pediatric" conditions and further training PED staff on how to care for adult patients are essential.