Improving Anaphylaxis Care: The Impact of a Clinical Pathway.

BACKGROUND: Recommended durations of observation after anaphylaxis have been widely variable, with many ranging from 4 to 24 hours. Prolonged durations often prompt admission for ongoing observation. METHODS: In a multidisciplinary quality improvement initiative, we revised our emergency department (ED) anaphylaxis clinical pathway. Our primary aim was to safely decrease the recommended length of observation from 8 to 4 hours and thereby decrease unnecessary hospitalizations. Secondary aims included provider education on anaphylaxis diagnostic criteria, emphasizing epinephrine as first-line therapy, and implementing a practice of discharging ED patients with an epinephrine autoinjector in hand. The study period consisted of the 18 months before pathway revision (baseline) and the 18 months after revision. RESULTS: The overall admission rate decreased from 58.2% (106 of 182) in the baseline period to 25.3% (65 of 257) after pathway revision (P < .0001). There was no significant difference in the percentage of patients returning to the ED within 72 hours, and there were no adverse outcomes or deaths throughout the study period. After pathway revision, the median time to first epinephrine administration for the most critical patients was 10 minutes, and 85.4% (164 of 192) of patients were discharged with an epinephrine autoinjector in hand. CONCLUSIONS: By revising an anaphylaxis clinical pathway, we were able to streamline the care of patients with anaphylaxis presenting to a busy pediatric ED, without any compromise in safety. Most notably, decreasing the recommended length of observation from 8 to 4 hours resulted in a near 60% reduction in the average rate of admission.

Hyperthyroidism Presenting With Pathologic Fractures.

Previous studies have shown that thyroid hormone directly stimulates bone resorption in in vitro organ culture, and in adults excess thyroid hormone is associated with decreased bone mineral density. There are limited data in children regarding the effect of hyperthyroidism on bone metabolism and even fewer instances in the literature of hyperthyroidism presenting with bone demineralization and fracture. We report a case of an 11-year-old boy with undiagnosed hyperthyroidism presenting with fractures and osteoporosis. This case emphasizes the importance of maintaining a broad differential diagnosis when a patient presents with a pathologic fracture.

Unscheduled revisits to a pediatric emergency department: risk factors for children with fever or infection-related complaints.

OBJECTIVE: Unscheduled revisits (URVs) may serve as markers of quality of care and may be costly both in financial terms as well as in limitations they place on primary care. We performed this study to examine the association between characteristics easily obtainable during an emergency department (ED) visit and URV to identify a subpopulation of children who may warrant interventions to decrease URV. METHODS: This is a case-control study of patients visiting an urban tertiary care pediatric ED for a fever or infectious disease-related complaint. Cases were defined as patients who had URVs that occurred within 72 hours of an initial ED visit. Control patients were selected by simple random sampling of an enumerated computerized list of all ED visits. Data on independent variables of interest were collected from a chart review and telephone interview with the patient's caregiver. Bivariate and multivariate analyses were performed to determine factors associated with URV. RESULTS: Seventy-five percent of cases and controls participated in the study. Logistic regression analysis revealed 3 factors independently associated with URV for fever or infectious disease-related complaints in children. These included presence of chronic disease (adjusted odds ratio 1.75, 95% confidence interval 1.01-3.03), Medicaid insurance (adjusted odds ratio 1.86, 95% confidence interval 1.04-3.32) and acute triage category (adjusted odds ratio 1.83, 95% confidence interval 1.08-3.10). CONCLUSIONS: These factors may be used to identify children in the ED at greater risk for URV and may point to a need for improved discharge instructions and enhanced communication with primary care and systems to arrange follow-up. Results of this work may also identify at-risk populations for future qualitative research or intervention studies on URV to EDs.

Return visits to a pediatric emergency department.

OBJECTIVES: To determine the incidence of return visits (RVs), types of RVs, and factors associated with RVs to a pediatric emergency department (ED). METHODS: : Retrospective cohort study of patients seen in an urban, tertiary care pediatric ED. MAIN OUTCOME: RV within 48 hours, identified from a computerized log. RESULTS: The total RV rate was 3.5% (95% confidence interval, 3.3-3.6), similar to rates (2.4% to 3.4%) reported in general EDs. Most (78.5%) RVs were unscheduled, 17% were scheduled, and 4% were called back to the ED. Infectious disease (45%), respiratory (16%), and trauma (16%) accounted for most RV diagnoses. When compared with the overall ED population, RV patients were more likely to be younger than 2 years [relative risk, 1.3 (1.2-1.4)], to be admitted to the hospital [relative risk, 1.3 (1.2-1.5)], and to be triaged as acute [relative risk, 1.1 (1.0-1.2)]. Patients called back to the ED were younger, more likely to be triaged as acute, and more likely to be admitted than other RV patients. Significant diagnoses were made at RV in 7 (0.4%; 95% confidence interval, 0.1-0.7) patients, half of whom were called back to the ED or had a scheduled RV. CONCLUSION: Similarities between our pediatric ED RV rate and other published research implies that benchmarking and quality improvement tools for RV can be used and compared in both pediatric and general EDs. Focusing on systems to call patients back to the ED when necessary may be an efficient way to reduce medical error and adverse patient outcomes.