Daniel A. Hirsh

Trends in Computed Tomography Utilization in the Pediatric Emergency Department

OBJECTIVE: The purpose of this study was to determine the overall trend of computed tomography (CT) utilization in the pediatric emergency department (PED) from 2003 to 2010 and to determine trends categorized by common chief complaints. METHODS: Electronic chart records at 2 tertiary care PEDs within a large pediatric health care system were reviewed from January 2003 through December 2010. The annual CT utilization rate, by anatomic location, was determined. Annual CT utilization rates were compared with alternative imaging trends for visits with chief complaints of head injury, seizure, and abdominal pain. Analysis was performed with linear regression. RESULTS: There was no change in overall CT utilization from 2003 to 2010 (β 0.25, 95% confidence interval [CI] [−1.61 to 2.73]) or within anatomic subgroups. Head CT utilization for the chief complaints of seizure (β −0.97, 95% CI [−1.44 to −0.90]) and head injury (β −0.93, 95% CI [−1.71 to −0.73]) showed significant declines. Although there was no change in the abdominal CT utilization rate for abdominal pain, abdominal ultrasound utilization for abdominal pain significantly increased (β 0.89, 95% CI [0.25–0.79]). CONCLUSIONS: Our data showed no overall increase in CT utilization through 2010. In areas where alternative non–radiation-based modalities were options, there were decreased CT trends and increased use of potential alternative non–radiation-based modalities. This is the first large PED cohort study to show a decrease in CT utilization in recent years in a regional pediatric referral center and may correlate with increased awareness of radiation risk in children.

Cardiac disease in pediatric patients presenting to a pediatric ED with chest pain

BACKGROUND Chest pain is a frequent chief complaint among the pediatric population. To date, limited data exist on the full spectrum of emergent cardiac disease among such patients; and existing data have been limited to relatively small cohorts. OBJECTIVES The aims of the study were to investigate the emergent cardiac etiologies of chest pain in a large cohort of patients presenting to a tertiary care pediatric emergency department (PED) and to examine the use of resources (electrocardiogram, chest radiograph, echocardiogram, and laboratories) in those with and without cardiac-related chest pain. METHODS Patient visits to 2 tertiary care PEDs were evaluated over a 3 and half-year period. Records of patients less than 19 years of age with a chief complaint of chest pain and no history of cardiovascular disease were reviewed. Patients were categorized as having cardiac or noncardiac etiologies or history of cardiovascular disease at the time of discharge, based on PED attendings final diagnoses. Final diagnoses classified as emergent cardiac etiologies were determined a priori. RESULTS Four thousand four hundred thirty-six patients reported a chief complaint of chest pain during the study period. Three percent were excluded secondary to a history of heart disease. Only 24 (0.6%) of the remaining 4288 were determined to have chest pain of cardiac origin. Those with cardiac-related chest pain had a rate of admission of 50% compared to those without cardiac disease at 4% (P < .001). Nine patients had an arrhythmia, 6 had pericarditis, 4 had myocarditis, 3 had acute myocardial infarction, and 1 had pulmonary embolism and pneumopericardium. Ninety-two percent of the cardiac-related chest pain cohort received electrocardiograms compared to those without cardiac-related chest pain at 27% (P < .01). Only 1 (4%) of 24 subjects with cardiac-related chest pain had a prior emergency department visit within 72 hours suggesting a high detection rate upon initial presentation. The most common noncardiac etiologies for the chest pain were 56% musculoskeletal disorders; 12% related to wheezing, asthma, and cough; 8% infectious causes; 6% gastrointestinal; and 4% related to sickle cell anemia. CONCLUSION Cardiac-related chest pain in pediatric patients is rare but potentially serious. Arrhythmia was the most common cardiac-related etiology among this cohort. Those with myocarditis and myocardial infarction were the most acutely ill. An electrocardiogram in addition to history and physical examination was most useful in detecting relatively uncommon but significant cardiac-related chest pain. Using a thorough physical examination and potentially an electrocardiogram evaluation by a pediatric emergency care physician has an excellent rate of detection of cardiac-related causes.

Practice Characteristics That Influence Nonurgent Pediatric Emergency Department Utilization

OBJECTIVE The goal of this study was to determine what characteristics of a primary care pediatric practice are associated with nonurgent use of the pediatric emergency department (PED). METHODS Primary care practice characteristics were prospectively collected from 33 practices. Nonurgent and urgent visits to the PED for patients from these practices were analyzed retrospectively. A discriminant analysis classification model was used to identify practice characteristics that were associated with nonurgent versus urgent utilization of the PED. RESULTS Patients in the network of 33 practices accounted for 31 076 visits to the PED during the 12-month study period, 47% of which were classified as nonurgent. Based on the discriminant analysis classification model, discriminant patterns that predict the frequency of nonurgent utilization included the percentage of patients with Medicaid, total available sick slots to see patients per physician, closer distance to the PED, whether or not the nurse triage line notified all on-call physicians of disposition to the PED, whether it is practice policy to accept all walk-in sick visits, and ability of practice to have same-day turnaround of laboratory tests. CONCLUSIONS Nonurgent utilization of the PED by patients in a specific primary care practice can be predicted based on discriminant practice characteristics, several of which may be modifiable. Use of these predictive rules can be used to optimize pediatric services and policy to help mitigate the high volume of PED nonurgent visitation. Focused interventions on practice characteristics of significance may help reduce PED overcrowding and improve continuity of care.

Pediatric Emergency Department Overcrowding: Electronic Medical Record for Identification of Frequent, Lower Acuity Visitors. Can We Effectively Identify Patients for Enhanced Resource Utilization?

The objective of this study was to utilize the electronic medical record system to identify frequent lower acuity patients presenting to the Pediatric Emergency Department and to evaluate their impact on Pediatric Emergency Department overcrowding and resource utilization. The electronic medical records (EMR) of two pediatric emergency centers were reviewed from August 2002 to November 2004. Pediatric Emergency Department encounters that met any of the following criteria were classified as Visits Necessitating Pediatric Emergency Department care (VNEC): Disposition of admission, transfer or deceased; Intravenous fluids (IVF) or medications (excluding single antipyretic or antihistamine); Radiology or laboratory tests (excluding Rapid Strep); Fractures, dislocations, and febrile seizures. All other visits were classified as non-VNEC. ICD-9 (International Classification of Diseases, Ninth Revision) codes from the Pediatric Emergency Department encounters were defined as representing chronic or non-chronic conditions. Patients were then evaluated for utilization patterns, frequency of Emergency Department (ED) visits, chronic illness, and VNEC status. There were 153,390 patients identified, representing 255,496 visits (1.7 visits/patient, range 1-49). Overall, 189,998 visits (74%) required defined ED services and were categorized as VNEC, with the remaining 65,498 visits (26%) categorized as non-VNEC. With increasing visits, a steady decline in those requiring ED services was observed, with a plateau by visit six (VNEC 77% @ one visit, 64% @ six visits, p < 0.001). There were 141,765 patients seen fewer than four times, representing 92% of the patients and 74% of all visits (1.3 visits/patient, 225 visits/day). In contrast, 2664 patients disproportionately utilized the ED more than six times (maximum 49), representing 1.7% of patients and 9.8% of visits (9.4 visit/patient, 30 visits/day, p < 0.001). Excluding patients with chronic illness, 1074 patients also disproportionately utilized the ED more than six times (maximum 28), representing 0.7% of patients and 3.6% of visits (8.6 visit/patient, 11 visits/day, p < 0.001). While representing < 2% of patients, frequent lower acuity utilizers of ED services accounted for nearly 10% of all visits (30/day). Low acuity patients may require only limited additional marginal resources for their individual care. However, in aggregate, inefficiencies occur, especially when systems reach capacity constraints, at which point these patients utilize limited resources (manpower and space) that could more effectively be directed toward the more acutely ill and injured patients. Therefore, identification of these patients utilizing the electronic medical record will allow for targeted interventions of this subgroup to improve future resource allocation.

Pulmonary Embolism in the Pediatric Emergency Department

OBJECTIVE: To describe patients who present to the pediatric emergency department (PED) and are subsequently diagnosed with pulmonary embolism (PE). METHODS: Electronic medical records from 2003 to 2011 of a tertiary care pediatric health care system was retrospectively reviewed to identify patients <21 years who had a final International Classification of Diseases, Ninth Revision diagnosis of PE. Patient demographics, and hospital course were recorded. Adult validated clinical decision rules Wells criteria and Pulmonary Embolism Rule-out Criteria (PERC) were retrospectively applied. PERC identified 8 clinical criteria for adult patients using logistic regression modeling to exclude PE without additional diagnostic evaluation. If all criteria are met, further evaluation is not indicated. RESULTS: Of 1 185 794 PED visits, 105 patients had an ultimate diagnosis of PE. Twenty-five met study criteria, and all were admitted. Forty percent of these patients had PE diagnosed in the PED. The most common risk factors were BMI ≥25 (50%, 10 of 20), oral contraceptive use (38% 5 of 13 female patients), and history of previous thrombus without PE (28%, 7 of 25). When the PERC rule was applied retrospectively, 84% of patients could not be ruled out, indicating additional evaluation for PE was needed. CONCLUSIONS: Pulmonary embolism is rare in children but does occur. This study emphasizes risk factors among children that should raise the suspicion of PE. Additional studies are needed to further evaluate risk factors and signs and symptoms of PE to develop pediatric specific clinical decision rules to provide reliable and reproducible means of determining pretest probability of PE.

Pandemic H1N1 Influenza in the Pediatric Emergency Department: A Comparison With Previous Seasonal Influenza Outbreaks

STUDY OBJECTIVE We compare the acuity of pediatric emergency department (ED) patients between the ongoing H1N1 influenza pandemic and previous seasonal influenza outbreaks. METHODS An observational, cross-sectional analysis of patient visits at 2 pediatric tertiary care EDs was made for the following periods: (1) regional fall 2009 H1N1 influenza surge (August 17 to September 20, 2009), and (2) combined regional 2007 to 2009 early peak influenza seasons (January 28 to March 2, 2008, and February 2 to March 8, 2009). Proportions of admissions, return visits, and return visits resulting in admission were compared between the 2 periods. Subset analysis of patients with influenza-like illness was performed. RESULTS Of total visits, no difference was found in the proportions of hospital admissions between the 2009 H1N1 surge (18,503 visits) and the previous influenza seasons (29,002 visits): non-ICU 9.9% versus 10.4%, 95% confidence interval of the difference -0.07% to 1.0%; ICU 0.9% versus 0.9%, 95% CI of the difference -0.1% to 0.2%. Of patients with influenza-like illness, no difference was found in the proportions of non-ICU admissions between the 2009 H1N1 surge (7,064 visits) and the previous influenza seasons (8,489 visits): 4.8% versus 5.2%, 95% CI of the difference -0.3% to 1.1%, whereas the proportion of ICU admissions increased during the 2009 H1N1 surge: 0.3% versus 0.1%, 95% CI of the difference 0.05% to 0.4%. The proportions of return visits within 7 days, including those resulting in admission, were similar between the 2 periods for both the total ED population and the influenza-like illness subset. CONCLUSION The severity of illness during the 2009 H1N1 surge appeared similar to that of previous influenza seasons for the total population of the 2 pediatric tertiary care EDs, whereas an increase in the proportion of ICU admissions was observed for patients with influenza-like illness.

Ondansetron Use in the Pediatric Emergency Department and Effects on Hospitalization and Return Rates: Are We Masking Alternative Diagnoses?

STUDY OBJECTIVE We evaluate the effect of ondansetron use in cases of suspected gastroenteritis on the proportion of hospital admissions and return visits and assess whether children who receive ondansetron on their initial visit to the pediatric emergency department (ED) for suspected gastroenteritis return with an alternative diagnosis more frequently than those who did not receive ondansetron. METHODS This is a retrospective review of visits to 2 tertiary care pediatric EDs with an International Classification of Diseases, Ninth Revision diagnosis of vomiting or gastroenteritis. A logistic regression model was developed to determine the effect of ondansetron use during the initial pediatric ED visit on hospital admission, return to the pediatric ED within 72 hours, and admission on this return visit. For patients who returned within 72 hours and were admitted, hospital discharge records were reviewed. The proportions of alternative diagnoses, defined as a hospital discharge diagnosis that was not a continuation of gastroenteritis or vomiting, were compared between the groups. RESULTS During the 3-year study period (2005 to 2007), 34,117 patients met study criteria. Ondansetron was used for 19,857 (58.2%) of these patients on their initial pediatric ED visit. After controlling for differences between the groups, patients who received ondansetron were admitted on their initial visit less often: odds ratio (OR) 0.47 (95% confidence interval [CI] 0.42 to 0.53). However, those who received ondansetron were more likely to return to the pediatric ED within 72 hours (OR 1.45; 95% CI 1.27 to 1.65) and be admitted on the return visit (OR 1.74; 95% CI 1.39 to 2.19). The proportions of alternative diagnoses at hospital discharge were not significantly different in the group that received ondansetron on the initial pediatric ED visit (14.9%) compared with the group that did not (22.4%) (absolute difference 7.5% [95% CI -0.5% to 16.4%). CONCLUSION Ondansetron use in the pediatric ED reduces hospital admissions for suspected gastroenteritis and vomiting. However, children who receive ondansetron in the pediatric ED appear more likely to return to the pediatric ED and be admitted on this return visit than their counterparts. Furthermore, the use of ondansetron does not appear to be associated with increased risks of masking serious diagnoses in children.

Ondansetron use in the pediatric emergency room for diagnoses other than acute gastroenteritis.

Background Ondansetron is widely used in the pediatric emergency department (PED) for vomiting and acute gastroenteritis (GE). Little is known about the spectrum of its use in diagnoses other than acute GE. Objective The objective of this study was to evaluate the spectrum of diagnoses for which ondansetron is used in the PED. Methods Medical records from 2 tertiary care PEDs from January 2006 to December 2008 were retrospectively reviewed. Patients 3 months to 18 years of age given ondansetron in the PED were identified. Patients without a primary discharge diagnosis (based on International Classification of Diseases, Ninth Revision code) of vomiting or GE were defined as non-GE. Patient age, initial triage level (1 = lowest acuity, 5 = highest), route of administration (enteral vs parenteral), primary diagnosis, disposition, and prescription for ondansetron at discharge were recorded; GE and non-GE patients were compared based on age and triage acuity. Results There were 32,971 patients who received ondansetron in the PED; 12,620 (38%) were non-GE patients. Non-GE patients were older (8.3 vs 4.3 years, P < 0.001) and of higher average initial triage level (2.95 vs 2.33, P < 0.001) compared with GE patients. Within non-GE patients, 79% received ondansetron enterally, 71% were discharged, and 37% of those discharged received an ondansetron prescription. The most common primary diagnoses for non-GE discharged patients were fever (15%), abdominal pain/tenderness (13%), head injury/concussion (7%), pharyngitis (6%), viral infection (6%), migraine variants (5%), and otitis media (5%). The most common diagnoses of patients admitted were appendicitis (11%), asthma (6%), pneumonia (4%), and diabetes (4%). Conclusions Although ondansetron is a widely accepted treatment for GE in children, this study identifies a broader spectrum of primary diagnoses for which ondansetron is being used.

Potential impact of peripheral intravenous catheter placement on resource use in the pediatric emergency department.

Objectives: In an era of pediatric emergency department (PED) overcrowding and diminishing health care resources, routine peripheral intravenous (PIV) catheter placement in the pediatric population requires evaluation because it might directly impact PED efficiency. This study aims to determine the utility of routine PIV catheter placement during phlebotomy. Methods: Electronic medical and billing records from 2 tertiary care PEDs during 1 year in patients 21 years or younger were analyzed. Data on the presence of PIV catheter placement in the PED, subsequent PIV catheter usage, chief complaint, and demographics were tabulated and analyzed. Results: During the study period, there were 131,003 PED visits analyzed and 26,776 PIV catheters placed. Of those placed, 12,475 (47%) were not used. The median age of the patients who received a PIV catheter that was not subsequently used was 36 months. The frequency of unused PIV catheters correlates with lower initial triage acuity. The highest rate of unused PIV catheter was in those 1 to 6 months old (63%), followed by that in groups younger than 1 month (57%), older than 6 to 24 months (52%), and older than 24 months (41%). Conclusions: Nearly half of the PIV catheters placed in the PED were unused. Unused PIV catheters represent an inefficient use of limited resources that could be redistributed to improve ED efficiency, flow, and resource use.

Reconnecting Patients With Their Primary Care Provider An Intervention for Reducing Nonurgent Pediatric Emergency Department Visits

Objective. Intervention to reduce nonurgent pediatric emergency department (PED) visits over a 12-month follow-up. Methods. Prospective, randomized, controlled trial enrolled children seen in the PED for nonurgent concerns. Intervention subjects received a structured session/handout specific to their primary care provider (PCP), which outlined ways to obtain medical advice. Visitation to the PED and PCP were followed over 12 months. Results. A total of 164 patients were assigned to the intervention and 168 patients to the control. At 12-month follow-up, the intervention group had a lower rate of nonurgent PED utilization compared with the control group (70 [43%] patients in the intervention compared with 91 [54%] in the control; P = .047). At 12 months, there was an increase in the rate of sick visits to PCP in the intervention group when compared with the control (P = .036). Conclusions. Intervention designed in cooperation with pediatricians was able to decrease nonurgent PED utilization and redirect patients to their PCP for future sick visits over a 12-month period.