Clinicians' perceptions of the health status of formerly detained immigrants.

BACKGROUND: In the past decade, the U.S. immigration detention system regularly detained more than 30,000 people per day; in 2019 prior to the pandemic, the daily detention population exceeded 52,000 people. Inhumane detention conditions have been documented by internal government watchdogs, and news media and human rights groups who have observed over-crowding, poor hygiene and sanitation and poor and delayed medical care, as well as verbal, physical and sexual abuse. METHODS: This study surveyed health professionals across the United States who had provided care for immigrants who were recently released from immigration detention to assess clinician perceptions about the adverse health impact of immigration detention on migrant populations based on real-life clinical encounters. There were 150 survey responses, of which 85 clinicians observed medical conditions attributed to detention. RESULTS: These 85 clinicians reported seeing a combined estimate of 1300 patients with a medical issue related to their time in detention, including patients with delayed access to medical care or medicine in detention, patients with new or acute health conditions such as infection and injury attributed to detention, and patients with worsened chronic or special needs conditions. Clinicians also provided details regarding sentinel cases, categorized into the following themes: Pregnant women, Children, Mentally Ill, COVID-19, and Other serious health issue. CONCLUSIONS: This is the first survey, to our knowledge, of health care professionals treating individuals upon release from detention. Due to the lack of transparency by federal entities and limited access to detainees, this survey serves as a source of credible information about conditions experienced within immigration detention facilities and is a means of corroborating immigrant testimonials and media reports. These findings can help inform policy discussions regarding systematic changes to the delivery of healthcare in detention, quality assurance and transparent reporting.

Regionalization Patterns for Children with Serious Trauma in California (2005-2015): A Retrospective Cohort Study.

OBJECTIVE: Trauma centers provide coordinated specialty care and have been demonstrated to save lives. Many states do not have a comprehensive statewide trauma system. Variable geography, resources, and population distributions present significant challenges to establishing an effective uniform system for pediatric trauma care. We aimed to identify patterns of primary (field) triage and transfer of serious pediatric trauma throughout California. We hypothesized that pediatric primary triage to trauma center care would be positively associated with younger age, increased injury severity, and local emergency medical service (EMS) regions with increased resources. We hypothesized that pediatric trauma transfer would be associated with younger age, increased injury severity, and rural regions with decreased resources. Methods: We conducted a retrospective cohort study of the California Office of Statewide Health Planning and Development emergency department and inpatient discharge data (2005-2015). All patients with serious injury, defined as Injury Severity Score (ISS) >9 were included. Demographic, injury, hospital, and regional characteristics such as distances between patient residence and destination hospitals were tabulated. Univariate and multinomial logit analyses were conducted to analyze individual, hospital, and regional characteristics associated with the outcomes of location of primary triage and transfer. Estimates were converted into predicted probabilities for ease of data interpretation. Results: Primary triage to was to either a pediatric trauma center (37.8%), adult level I/II trauma center (35.0%), adult level III/IV trauma center (1.9%), pediatric non-trauma hospital (3.4%), or an adult non-trauma hospital (21.9%).Younger age, private non-HMO insurance, motor vehicle mechanism, and rural areas were the major factors influencing primary triage to any trauma hospital. Younger age, private non-HMO insurance, higher ISS, fall mechanism, <200 bed hospital, and rural areas were the major factors influencing transfer from a non-trauma hospital to any trauma center. Conclusions: We demonstrate statewide primary triage and transfer patterns for pediatric trauma in a large and varied state. Specifically we identified previously unrecognized individual, hospital, and EMS system associations with pediatric trauma regionalization. Knowledge of these de facto trauma care access patterns has policy and process implications that could improve care for all injured children in need.

Variations in access to specialty care for children with severe burns.

BACKGROUND: Pediatric burns account for 120,000 emergency department visits and 10,000 hospitalizations annually. The American Burn Association has guidelines regarding referrals to burn centers; however there is variation in burn center distribution. We hypothesized that disparity in access would be related to burn center access. METHODS: Using weighted discharge data from the Nationwide Inpatient Sample 2001-2011, we identified pediatric patients with International Classification of Diseases-9th Revision codes for burns that also met American Burn Association criteria. Key characteristics were compared between pediatric patients treated at burn centers and those that were not. RESULTS: Of 54,529 patients meeting criteria, 82.0% (n = 44,632) were treated at burn centers. Patients treated at burn centers were younger (5.6 versus 6.7 years old; p < 0.0001) and more likely to have burn injuries on multiple body regions (88% versus 12%; p < 0.0001). In urban areas, 84% of care was provided at burn centers versus 0% in rural areas (p < 0.0001), a difference attributable to the lack of burn centers in rural areas. Both length of stay and number of procedures were significantly higher for patients treated at burn centers (7.3 versus 4.4 days, p < 0.0001 and 2.3 versus 1.1 procedures, p < 0.0001; respectively). There were no significant differences in mortality (0.7% versus 0.8%, p = 0.692). CONCLUSION: The majority of children who met criteria were treated at burn centers. There was no significant difference between geographical regions. Of those who were treated at burn centers, more severe injury patterns were noted, but there was no significant mortality difference. Further study of optimal referral of pediatric burn patients is needed.

Correction to: Epidemiology of patients presenting to a pediatric emergency department in Karachi, Pakistan.

An amendment to this paper has been published and can be accessed via the original article.

Timely access to care for patients with critical burns in India: a prehospital prospective observational study.

BACKGROUND: Low/middle-income countries carry a disproportionate burden of the morbidity and mortality from thermal burns. Nearly 70% of burn deaths worldwide are from thermal burns in India. Delays to medical care are commonplace and an important predictor of outcomes. We sought to understand the role of emergency medical services (EMS) as part of the healthcare infrastructure for thermal burns in India. METHODS: We conducted a prospective observational study of patients using EMS for thermal burns across five Indian states from May to August 2015. Our primary outcome was mortality at 2, 7 and 30 days. We compared observed mortality with expected mortality using the revised Baux score. We used Χ2 analysis for categorical variables and Wilcoxon two-sample test for continuous variables. ORs and 95% CIs are reported for all modelled predictor variables. RESULTS: We enrolled 439 patients. The 30-day follow-up rate was 85.9% (n=377). The median age was 30 years; 56.7% (n=249) lived in poverty; and 65.6% (n=288) were women. EMS transported 94.3% of patients (n=399) to the hospital within 2 hours of their call. Median total body surface area (TBSA) burned was 60% overall, and 80% in non-accidental burns. Sixty-eight per cent of patients had revised Baux scores greater than 80. Overall 30-day mortality was 64.5%, and highest (90.2%) in women with non-accidental burns. Predictors of mortality by multivariate regression were TBSA (OR 7.9), inhalation injury (OR 5.5), intentionality (OR 4.7) and gender (OR 2.2). DISCUSSION: Although EMS rapidly connects critically burned patients to care in India, mortality remains high, with women disproportionally suffering self-inflicted burns. To combat the burn epidemic in India, efforts must focus on rapid medical care and critical care services, and on a burn prevention strategy that includes mental health and gender-based violence support services.

Epidemiology of patients presenting to a pediatric emergency department in Karachi, Pakistan.

BACKGROUND: There is little data describing pediatric emergencies in resource-poor countries, such as Pakistan. We studied the demographics, management, and outcomes of patients presenting to the highest-volume, public, pediatric emergency department (ED) in Karachi, Pakistan. METHODS: In this prospective, observational study, we approached all patients presenting to the 50-bed ED during 28 12-h study periods over four consecutive weeks (July 2013). Participants' chief complaints and medical care were documented. Patients were followed-up at 48-h and 14-days via telephone. RESULTS: Of 3115 participants, 1846 were triaged to the outpatient department and 1269 to the ED. Patients triaged to the ED had a median age of 2.0 years (IQR 0.5-4.0); 30% were neonates (< 28 days). Top chief complaints were fever (45.5%), diarrhea/vomiting (32.3%), respiratory (23.1%), abdominal (7.5%), and otolaryngological problems (5.8%). Temperature, pulse and respiratory rate, and blood glucose were documented for 66, 42, and 1.5% of patients, respectively. Interventions included medications (92%), IV fluids (83%), oxygen (35%), and advanced airway management (5%). Forty-five percent of patients were admitted; 11 % left against medical advice. Outcome data was available at time of ED disposition, 48-h, and 14 days for 83, 62, and 54% of patients, respectively. Of participants followed-up, 4.3% died in the ED, 11.5% within 48 h, and 19.6% within 14 days. CONCLUSIONS: This first epidemiological study at Pakistan's largest pediatric ED reveals dramatically high mortality, particularly among neonates. Future research in developing countries should focus on characterizing reasons for high mortality through pre-ED arrival tracking, ED care quality assessment, and post-ED follow-up.

Variations in Utilization of Inpatient Rehabilitation Services among Pediatric Trauma Patients.

OBJECTIVE: To assess clinical and nonclinical characteristics associated with the use of pediatric inpatient rehabilitation services among children with traumatic injuries. We hypothesized there would be no nonclinical variations in the use of pediatric inpatient rehabilitation services. STUDY DESIGN: Retrospective analysis of 1139 patients who were injured seriously (0-18 years of age) from our institutional trauma registry (2004-2014). Patients' nonclinical and clinical characteristics were analyzed. We used a full matching technique to compare characteristics between those admitted to rehabilitation (cases) to those discharged home (controls). We matched patients by age category, sex, maximum Abbreviated Injury Scale, and body region of maximum Abbreviated Injury Scale. We used survey-based multivariate logistic regression to identify characteristics associated with inpatient rehabilitation services, controlling for multiple injuries, distance from home to rehabilitation center, year of service, hospital length of stay, and clinically relevant interactions. RESULTS: Ninety-eight patients (8.6%) were admitted to inpatient rehabilitation and 968 (85.0%) were discharged home. Black and other minority patients had increased odds of receiving inpatient rehabilitation compared with white patients (OR, 7.6 [P< .001] and OR, 1.6 [P= .03], respectively). Patients with private compared with public insurance had increased odds of receiving inpatient rehabilitation (OR, 2.4; P< .001). CONCLUSIONS: Pediatric inpatient rehabilitation beds are a scarce resource that should be available to those with the greatest clinical need. The mechanism creating differences in the use of inpatient rehabilitation based on nonclinical characteristics such as race/ethnicity or insurance status must be understood to prevent disparities in access to inpatient rehabilitation services.

Variation in the Intensity of Care for Patients with Uncomplicated Renal Colic Presenting to U.S. Emergency Departments.

BACKGROUND: Renal colic results in > 1 million ED visits per year, yet there exists a gap in understanding how the majority of these visits, namely uncomplicated cases, are managed. OBJECTIVE: We assessed patient- and hospital-level variation for emergency department (ED) management of uncomplicated kidney stones. METHODS: We identified ED visits from non-elderly adults (aged 19-79 years) with a primary diagnosis indicating renal stone or colic from the 2011 Nationwide Emergency Department Sample. Patients with additional diagnostic codes indicating infection, sepsis, and abdominal aortic aneurysm were excluded. We used sample-weighted logistic regression to determine the association between hospital admission and having a urologic procedure with patient and hospital characteristics. RESULTS: Of the 1,061,462 ED visits for uncomplicated kidney stones in 2011, 8.0% of visits resulted in admission and 6.3% resulted in an inpatient urologic procedure. Uninsured patients compared to Medicaid insured patients were less likely to be admitted or have an inpatient urologic procedure (odds ratio [OR] = 0.72; 95% confidence interval [CI] 0.65-0.81 and OR = 0.80; 95% CI 0.72-0.87, respectively). Private- and Medicare-insured patients compared to Medicaid-insured patients were more likely to have an inpatient urologic procedure (OR = 1.20; 95% CI 1.11-1.30 and OR = 1.14; 95% CI 1.04-1.25, respectively). CONCLUSIONS: For patients with uncomplicated renal colic, there is variation in the management associated with nonclinical factors, namely insurance. No consensus guidelines exist yet to address when to admit or utilize inpatient urologic procedures.

The 6-Minute Walk Test as a Predictor of Summit Success on Denali.

OBJECTIVE: To test whether the 6-minute walk test (6MWT), including postexercise vital sign measurements and distance walked, predicts summit success on Denali, AK. METHODS: This was a prospective observational study of healthy volunteers between the ages of 18 and 65 years who had been at 4267 m for less than 24 hours on Denali. Physiologic measurements were made after the 6MWT. Subjects then attempted to summit at their own pace and, at the time of descent, completed a Lake Louise Acute Mountain Sickness Questionnaire and reported maximum elevation reached. RESULTS: One hundred twenty-one participants enrolled in the study. Data were collected on 111 subjects (92% response rate), of whom 60% summited. On univariate analysis, there was no association between any postexercise vital sign and summit success. Specifically, there was no significant difference in the mean postexercise peripheral oxygen saturation (Spo2) between summiters (75%) and nonsummiters (74%; 95% CI, -3 to 1; P = .37). The distance a subject walked in 6 minutes (6MWTD) was longer in summiters (617 m) compared with nonsummiters (560 m; 95% CI, 7.6 to 106; P = .02). However, this significance was not maintained on a multivariate analysis performed to control for age, sex, and guide status (P = .08), leading to the conclusion that 6MWTD was not a robust predictor of summit success. CONCLUSIONS: This study did not show a correlation between postexercise oxygen saturation or 6MWTD and summit success on Denali.

An observational study of adults seeking emergency care in Cambodia.

OBJECTIVE: To describe the characteristics and chief complaints of adults seeking emergency care at two Cambodian provincial referral hospitals. METHODS: Adults aged 18 years or older who presented without an appointment at two public referral hospitals were enrolled in an observational study. Clinical and demographic data were collected and factors associated with hospital admission were identified. Patients were followed up 48 hours and 14 days after presentation. FINDINGS: In total, 1295 hospital presentations were documented. We were able to follow up 85% (1098) of patients at 48 hours and 77% (993) at 14 days. The patients' mean age was 42 years and 64% (823) were females. Most arrived by motorbike (722) or taxi or tuk-tuk (312). Most common chief complaints were abdominal pain (36%; 468), respiratory problems (15%; 196) and headache (13%; 174). Of the 1050 patients with recorded vital signs, 280 had abnormal values, excluding temperature, on arrival. Performed diagnostic tests were recorded for 539 patients: 1.2% (15) of patients had electrocardiography and 14% (175) had diagnostic imaging. Subsequently, 783 (60%) patients were admitted and 166 of these underwent surgery. Significant predictors of admission included symptom onset within 3 days before presentation, abnormal vital signs and fever. By 14-day follow-up, 3.9% (39/993) of patients had died and 19% (192/993) remained functionally impaired. CONCLUSION: In emergency admissions in two public hospitals in Cambodia, there is high admission-to-death ratio and limited application of diagnostic techniques. We identified ways to improve procedures, including better documentation of vital signs and increased use of diagnostic techniques.

Epidemiology of Shortness of Breath in Prehospital Patients in Andhra Pradesh, India.

BACKGROUND: Shortness of breath is a frequent reason for patients to request prehospital emergency medical services and is a symptom of many life-threatening conditions. To date, there is limited information on the epidemiology of, and outcomes of patients seeking emergency medical services for, shortness of breath in India. OBJECTIVE: This study describes the characteristics and outcomes of patients with a chief complaint of shortness of breath transported by a public ambulance service in the state of Andhra Pradesh, India. METHODS: This prospective, observational study enrolled patients with a chief complaint of shortness of breath during twenty-eight, 12-h periods. Demographic and clinical data were collected from emergency medical technicians using a standardized questionnaire. Follow-up information was collected at 48-72 h and 30 days. RESULTS: Six hundred and fifty patients were enrolled during the study period. The majority of patients were male (63%), from rural communities (66%), and of lower socioeconomic status (78%). Prehospital interventions utilized included oxygen (76%), physician consultation (40%), i.v. placement (15%), nebulized medications (13%), cardiopulmonary resuscitation (5%), and bag-mask ventilation (4%). Mortality ratios before hospital arrival, at 48-72 h, and 30 days were 12%, 27%, and 35%, respectively. Forty-six percent of patients were confirmed to have survived to 30 days. Predictors of death before hospital arrival were symptoms of chest pain (16% vs. 12%; p < 0.05) recent symptoms of upper respiratory infection (7.5% vs. 4%; p < 0.05), history of heart disease (14% vs. 7%; p < 0.05), and prehospital hypotension, defined as systolic blood pressure <90 mm Hg (6.3% vs. 3.7%; p < 0.05). CONCLUSIONS: Among individuals seeking prehospital emergency medical services in India, the chief complaint of shortness of breath is associated with a substantial early and late mortality, which may be in part due to the underutilization of prehospital interventions.

Emergency department-based health insurance enrollment for children: does linkage lead to insurance retention and utilization?

OBJECTIVES: Although 40% of emergency departments (EDs) report having an insurance linkage program, no studies have evaluated the long-term success of these programs. This study aimed to examine insurance retention and utilization by children initially referred to insurance by our ED insurance linkage program. METHODS: We retrospectively examined insurance records of all uninsured children successfully enrolled in public insurance by the insurance linkage program established in our suburban academic ED between 2004 and 2009. Emergency department-enrolled children were matched by age, sex, program, and year of enrollment to a control group of children from the same county who were enrolled in non-ED settings. Wilcoxon signed rank and χ tests were used to compare enrollment and claims variables. RESULTS: Emergency department-enrolled children retained insurance for longer, had a higher reenrollment rate, and were higher users of insurance. The average length of enrollment for ED children was 734 days versus 597 days in the control group. Eighty percent of the ED cohort reenrolled in insurance after initial eligibility expiration versus 64% of the control group. Children enrolled via the ED averaged 26 claims (vs 12 claims) and $20,087 (vs $5216) in hospital charges per year of enrollment. This higher utilization was reflected in increased primary care, specialty care, ED visits, inpatient, and mental health claims in the ED group. CONCLUSIONS: Emergency department-based insurance enrollment programs have the potential to improve access to health care for children. Policies aimed at expanding insurance enrollment among the uninsured population, including the Affordable Care Act, may consider the ED's potential as an effective enrollment site.

Clinical correlation needed: what do emergency physicians do after an equivocal ultrasound for pediatric acute appendicitis?

BACKGROUND: Although follow-up CT is recommended for pediatric appendicitis if initial ultrasound (US) is equivocal, many physicians observe the patient at home. There are limited data to understand currently how common or safe this practice is. Our objectives are to assess prevalence of acute appendicitis and outcomes in patients with equivocal US with and without follow-up CT and to identify variables associated with ordering a follow-up CT. METHODS: Retrospective analysis of the prevalence of appendicitis and outcomes of patients 1-18 years old with an equivocal US at a pediatric emergency department from 2003 to 2008. Recursive partitioning analysis and multivariate logistic regression were used to identify variables associated with ordering follow-up CT. RESULTS: Fifty-five percent (340/620) of children with equivocal US did not receive CT, none of whom returned with a missed appendicitis. The prevalence of appendicitis in children with equivocal US was 12.5% (78/620). In children with follow-up CT, the prevalence was 22.1% (62/280); in those without follow-up CT, the prevalence was 4.7% (16/340). Recursive partitioning identified age >11 years, leukocytosis >15,000 cells/ml, and secondary signs predisposing toward acute appendicitis on US as significant predictors of CT. CONCLUSIONS: We view our study as a fundamental part of the incremental progress to understand how best to use US and CT imaging to diagnose pediatric appendicitis while minimizing ionizing radiation. Children at low risk for appendicitis with equivocal US are amenable to observation and reassessment prior to reimaging with US or CT.

Waiting for Care: Length of Stay for ED Mental Health Patients by Disposition, Diagnosis, and Region (2009-2015).

Objective Emergency departments (EDs) face increasing mental health visits on a backdrop of insufficient mental health resources. We study ED length of stay (LOS) and disposition by 1) mental health vs. medical visits; 2) psychiatric vs. substance use visits; and 3) the four regions of the United States.  Methods We used weighted data from the National Hospital Ambulatory Medical Care Survey (2009-2015). Visits by patients ages 18-64 were categorized into mental health and medical groups. The mental health group was then subdivided into psychiatric, substance use, and co-occurring disorders. The LOS was compared by disposition. Mental health vs. medical LOS and disposition were examined across four regions of the US. Results An estimated 28 million mental health and 526 million medical visits were included in the study. Mental health visits had a median (interquartile range [IQR]) of 3.7 (4.7) hours while medical visits had a median (IQR) of 2.6 (2.7) hours. Mental health compared to medical visits were more likely to result in admission or transfer and to last >6 and >12 hours. Mental health visits resulting in transfer had the longest LOS with a median (IQR) of 6.23 (7.7) hours. Of mental health visit types, co-occurring disorders visits were more likely to be >6 and >12 hours regardless of disposition. Across US regions, there was significant variation in disposition patterns for mental health vs. medical visits. The odds of mental health visits lasting >6 and >12 hours were greatest in the Northeast and the least in the South with a median (IQR) of 4.6 (5.8) hours and 3.3 (4.0) hours, respectively. Conclusions Metal health compared to medical visits had longer LOS, especially when the patient had co-occurring disorders or required transfer. Regionally, there is a large variation in disposition for mental health vs. medical visits. This study makes it clear that there are no standards for managing psychiatric emergencies.

A retrospective observational cohort study: Epidemiology and outcomes of pediatric unintentional falls in US emergency departments.

INTRODUCTION: The objective is to determine how outcomes from unintentional falls differ for children with and without developmental disabilities, with a sensitivity analysis specifically examining those with ADHD. MATERIALS AND METHODS: This is a retrospective observational cohort study of 2010-2015 data from the Nationwide Emergency Department Sample (NEDS). The NEDS is a sampling of ED visits across 953 hospitals in 36 states. Unintentional falls for children with and without developmental disabilities were compared, adjusting for age, sex, payment source, income, mechanism, injury severity score (ISS). A sensitivity analysis was then performed for children with ADHD (n=139,642) and those without any developmental disabilities. A priori chosen outcomes included hospital admission, length of stay, intubation, and surgery. Logistic regression analysis estimated adjusted odds ratios for outcomes. RESULTS: Among children who presented to the ED with unintentional falls (n=13,217,237), there were 223,445 (1.7%) with developmental disabilities. The majority of those with developmental disabilities were male, ages 10-14 years. Compared to children without developmental disabilities, those with developmental disabilities were more likely to have an inpatient admission (aOR=2.27, 95% CI=2.10-2.44), length of stay more than 2 days (aOR=1.73, 95% CI=1.51-1.98), intubation (aOR=4.77, 95% CI=3.62-6.27) and surgery (aOR=2.11, 95% CI=1.93-2.32). A sensitivity analysis showed that 139,642 (1%) of children ages 5-17 years had ADHD. Of those with ADHD, the majority was also male, ages 10-14 years. Compared to children without ADHD, those with ADHD had a higher odds of inpatient admission (aOR=1.74, 95% CI=1.58-1.91), length of stay greater than 2 days (aOR=1.59, 95% CI=1.37-1.85), intubation (aOR=3.96, 95% CI=2.73-5.73), and surgery (aOR=1.82, 95% CI=1.60-2.06). CONCLUSIONS: Children with developmental disabilities, in particular those with ADHD, who experience falls are often older and male. They had greater odds of poor outcomes. These children need additional anticipatory guidance and attention to adequate treatment to prevent injuries from unintentional falls.

Emergency Department Access During COVID-19: Disparities in Utilization by Race/Ethnicity, Insurance, and Income.

INTRODUCTION: In March 2020, shelter-in-place orders were enacted to attenuate the spread of coronavirus 2019 (COVID-19). Emergency departments (EDs) experienced unexpected and dramatic decreases in patient volume, raising concerns about exacerbating health disparities. METHODS: We queried our electronic health record to describe the overall change in visits to a two-ED healthcare system in Northern California from March-June 2020 compared to 2019. We compared weekly absolute numbers and proportional change in visits focusing on race/ethnicity, insurance, household income, and acuity. We calculated the z-score to identify whether there was a statistically significant difference in proportions between 2020 and 2019. RESULTS: Overall ED volume declined 28% during the study period. The nadir of volume was 52% of 2019 levels and occurred five weeks after a shelter-in-place order was enacted. Patient demographics also shifted. By week 4 (April 5), the proportion of Hispanic patients decreased by 3.3 percentage points (pp) (P = 0.0053) compared to a 6.2 pp increase in White patients (P = 0.000005). The proportion of patients with commercial insurance increased by 11.6 pp, while Medicaid visits decreased by 9.5 pp (P < 0.00001) at the initiation of shelter-in-place orders. For patients from neighborhoods <300% federal poverty levels (FPL), visits were -3.8 pp (P = 0.000046) of baseline compared to +2.9 pp (P = 0.0044) for patients from ZIP codes at >400% FPL the week of the shelter-in-place order. Overall, 2020 evidenced a consistently elevated proportion of high-acuity Emergency Severity Index (ESI) level 1 patients compared to 2019. Increased acuity was also demonstrated by an increase in the admission rate, with a 10.8 pp increase from 2019. Although there was an increased proportion of high-acuity patients, the overall census was decreased. CONCLUSION: Our results demonstrate changing ED utilization patterns circa the shelter-in-place orders. Those from historically vulnerable populations such as Hispanics, those from lower socioeconomic areas, and Medicaid users presented at disproportionately lower rates and numbers than other groups. As the pandemic continues, hospitals should use operations data to monitor utilization patterns by demographic, in addition to clinical indicators. Messaging about availability of emergency care and other services should include vulnerable populations to avoid exacerbating healthcare disparities.

Patient, hospital and regional characteristics associated with undertriage of injured children in California (2005-2015): a retrospective cohort study.

BACKGROUND/OBJECTIVE: Trauma centers save lives, but they are scarce and concentrated in urban settings. The population of severely injured children in California who do not receive trauma center care (undertriage) is not well understood. METHODS: Retrospective observational study of all children (0-17 years) hospitalized for severe trauma in California (2005-2015). We used the California Office of Statewide Health Planning and Development linked Emergency Department and Inpatient Discharge data sets. Logistic regression models were created to analyze characteristics associated with undertriage. The model was clustered on differential distance between distance from residence to primary triage hospital and distance from residence to nearest trauma center. We controlled for body part injured, injury type, intent and year. The a priori hypothesis was that uninsured and publicly insured children and hospitals and regions with limited resources would be associated with undertriage. RESULTS: Twelve percent (1866/15 656) of children with severe injury experienced undertriage. Children aged >14 years compared with 0-13 years had more than 2.5 times the odds of undertriage (OR 2.58; 95% CI 2.1 to 3.16). Children with private Health Maintenance Organization (HMO) insurance compared with public insurance had 13 times the odds of undertriage (OR 12.62; 95% CI 8.95 to 17.79). Hospitals with >400 compared with <200 beds had more than three times the odds of undertriage (OR 3.64; 95% CI 2.6 to 5.11). Urban versus suburban residence had 1.3 times increased odds of undertriage (OR 1.31; 95% CI 1.02 to 1.67) Undertriage volume was largest in urban areas. CONCLUSION: Undertriage is associated with private HMO insurance, primary triage to large hospitals and urban residence. Understanding the characteristics associated with undertriage can help improve trauma systems. LEVEL OF EVIDENCE: Level III (non-experimental retrospective observational study).

Increasing ambulatory treatment of pediatric minor burns-The emerging paradigm for burn care in children.

INTRODUCTION: Innovations in topical burn treatment along with a drive toward value-based care are steering burn care to the outpatient setting. Little is known regarding what characteristics predict outpatient treatment of pediatric minor burns and whether there is a temporal trend toward this treatment paradigm. METHODS: A retrospective cohort study was performed using California's Office of Statewide Health Planning and Development linked emergency department and inpatient database (2005-2013). All patients under 18years of age with a primary burn diagnosis were extracted. Using patient and facility level variables, we used regression modeling to evaluate predictors of outpatient burn treatment and temporal trends. RESULTS: There were 16,480 pediatric minor burn encounters during the period. 56.4% were male, 85.3% had <10% total body surface area (TBSA), 76.3% were scald or contact, and 77.3% were at deepest depth 2nd degree. Multiple variables predicted an increased likelihood of discharge home including older age(p<0.001), smaller TBSA(p<0.001), and superficial/partial thickness burns(< 0.001). Children of Hispanic and Black race were less likely to be discharged home compared to White and Asian peers(p=<0.001). On Poisson modeling, the incidence rate ratio over the 9-year period for home discharge was 1.004 (95% CI 1.001-1.008, p=0.032). CONCLUSION: Older patients and those with more superficial burns were more likely to be treated as outpatients. Black and non-white Hispanic race was associated with inpatient admission. There is a growing trend toward ambulatory treatment of minor burns in the pediatric population. Further research is needed to assess whether outpatient treatment of pediatric minor burns results in greater readmissions.

Shifting the Paradigm of Emergency Care in Developing Countries.

Background The global agenda does not address a significant amount of preventable death in low- and middle-income countries (LMICs). While illnesses requiring acute care are increasing at an alarming rate in these countries, there are inadequate numbers of physicians or nurses to deal with the growing burden. Many people feel that emergency systems are too expensive and restricted in scope to have public health implications in resource-limited areas. Little empirical data exists to suggest otherwise. The goal of this study was to delineate the type and frequency of emergency conditions and define a novel method to estimate the burden of emergency diseases in Fort Liberte, Haiti. Methods A retrospective, cross-sectional medical record review was performed on all emergency room visits to Fort Liberte Hospital in 2009 and 2010. The type, frequency, and annual incidence of emergency conditions were identified and used to determine the burden of emergency disease. A disability-adjusted life year (DALY) calculation was estimated using a variation on a model of indirect national data extrapolation to cities. Results Nineteen months of data available yielded 2000 charts with 2284 diagnoses in total. Trauma was the most common illness at 13% of all charts, followed by abdominal pain at 11%, gastroenteritis at 8%, skin and soft tissue infections at 7%, and hypertension at 6%. The DALY calculation showed disability from emergency conditions to be five times that of HIV, malaria, and TB combined. Conclusions Sufficient emergency burden of disease affects population health in Fort Liberte, Haiti to warrant addressing it as a public health concern. The kinds of conditions described in this review may be amenable to task shifting as a feasible, sustainable, and scalable way to address the burden in a cost-effective manner.

Nationwide Assessment of Factors Associated with Nonoperative Management of Pediatric Splenic Injury.

To evaluate variation in care nationwide for children with splenic injuries at pediatric trauma, adult trauma, and nontrauma centers. We used the National Inpatient Sample from 2001 to 2010 to identify pediatric patients with splenic injury. We analyzed demographic, clinical, and hospital status characteristics. The primary objective was comparison of splenectomy rates at pediatric, adult, and nontrauma centers. We identified 34,599 patients with splenic injury. Throughout the study, 3,979 (11.5%) patients underwent splenectomy: 8.2 per cent of patients at pediatric trauma, 17.6 per cent at adult trauma, and 14.5 per cent at nontrauma centers. Multivariate regression analysis demonstrated patients had decreased odds of splenectomy at pediatric trauma centers compared with adult and nontrauma centers (OR = 0.42, P < 0.001). In addition, children aged 14 to 17 years (OR = 2.5) with injury severity score > 14 (OR = 5.8) had increased odds of undergoing splenectomy. In this nationwide sample, children with splenic injury treated at adult trauma and nontrauma centers had significantly higher rates of splenectomy compared with children treated at pediatric trauma centers. We highlight the need for interventions that ensure all injured children receive appropriate and high quality trauma care.