Naghma S. Khan

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.

Pediatric emergency physician interpretation of plain radiographs : Is routine review by a radiologist necessary and cost-effective ?

STUDY OBJECTIVE To determine the concordance rate of plain radiograph interpretations by pediatric emergency physicians and pediatric radiologists, to evaluate the effect of incorrect radiologic diagnosis on patient management, and to evaluate the necessity and cost-effectiveness of routine follow-up review of all plain radiographs by a radiologist. METHODS We assembled a prospective series of all patients who presented to the emergency department of an urban tertiary care childrens hospital and underwent plain radiography between October 1 and October 31, 1994. Pediatric emergency physicians documented their interpretations. Within 24 hours, films were reviewed by a pediatric radiologist. The two interpretations were classified as concordant or discordant and were further assessed for medical significance and subsequent change in management. RESULTS During the study period, 707 radiographic examinations were performed: chest, 56%; skeletal excluding spine, 20.1%; abdomen, 11.9%; sinus, 4.2%; spine, 3.6%; and other, 4%. The accuracy or concordance rate was 90.2% (638 of 707) for pediatric emergency physician interpretations; clinical management was unchanged in 96.9% (685 of 707) of the cases. Of the 69 discordant interpretations, 48 were clinically significant, with 22 requiring changes in management. They included 9 false-negative interpretations by pediatric emergency physicians: (5 fractures, 2 cases of pneumonia, 1 case of sinusitis, 1 case of cardiomegaly); 10 false-positive interpretations by pediatric emergency physicians (5 fractures, 4 cases of pneumonia, 1 case of sinusitis), and 3 false-positive interpretations by radiologists (1 case of C-2 spine subluxation, 1 retropharyngeal abscess, and 1 case of necrotizing enterocolitis). No adverse outcomes resulted from these misinterpretations. Routine review of all plain radiographs by a radiologist represents an estimated

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

210,000 annual cost to the patients and payers. CONCLUSION Radiograph interpretations by pediatric emergency physicians were generally accurate, and no adverse outcomes occurred as a result of misinterpretation. Clinical assessment probably assisted these physicians in interpreting the radiographs of high-risk patients. Judicious consultation with a radiologist during the initial presentation of a high-risk patient, when deemed warranted by the pediatric emergency physician, will help the emergency physician deliver high-quality, cost-effective health care. Given the overall clinical accuracy rate of radiograph interpretations by the pediatric emergency physicians and the cost of routine review of all plain radiographs in the ED by a radiologist, routine review versus selective specialty consultation must be further evaluated.

Quality initiatives in the 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.

Weapons detection at two urban hospitals

Purpose of review To report on recent advances in quality initiatives in emergency departments (EDs), with a special focus on applicability to pediatric EDs (PED) Recent findings Although healthcare quality improvement has made great strides in the last couple of decades, quality improvement efforts in pediatrics have lagged behind. Over the last decade, as quality initiatives have matured in adult hospitals, there has been a downstream effect on general EDs, as system-wide clinical guidelines are usually initiated through the ED – such efforts are being reported in the literature. There is significant overlap in quality improvement efforts in adult and pediatric EDs. In this article, we review the recent relevant articles, with particular emphasis on pediatrics where appropriate. Summary There is an opportunity in pediatric emergency medicine to reduce practice variability, decrease cost and improve efficiency of care. There is an urgent need to report the successes and failures of these initiatives, so we can develop benchmarks and optimize services provided in the PED.

Emergency Department Return Visits Resulting in Admission: Do They Reflect Quality of Care?

Objective To determine the type of weapons confiscated from an urban pediatric hospital and its affiliated general hospital. Methods This was a prospective evaluation of weapons confiscated from individuals entering 2 affiliated urban hospitals: a general hospital with over 85,000 emergency department visits and a freestanding children’s hospital with over 45,000 emergency department visits. The security personnel are common between the 2 hospitals and use similar confiscation protocols. The institutions were evaluated between January 1, 2000 and August 31, 2000, which followed the implementation of weapons detectors at the children’s hospital. The variety and scope of weapons confiscated were monitored. Results During the 8 months, 3706 metallic weapons were confiscated. This included 3446 from the general hospital and 260 from the children’s center. The weapons confiscated at the general hospital compared with the children’s hospital included guns (4 vs. 0), knives (2048 vs. 114), box cutter/razors (596 vs. 37), scissors (70 vs. 53), chemical sprays (205 vs. 50), tools (73 vs. 6), and other (450 vs. 0). Conclusions While more weapons were confiscated at the larger general hospital, the traditional sense that children’s hospitals are at minimal risk is unjustified. The alarming number of lethal concealed weapons confiscated from both institutions demonstrates the importance of deterrent security measures, including the use of metal detectors to protect families and staff.

The use of ondansetron for nausea and vomiting after head injury and its effect on return rates from the pediatric ED.

Prior studies have suggested that emergency department (ED) return visits resulting in admission may be a more robust quality indicator than all 72-hour returns. The objective was to evaluate factors that contribute to admission within 72 hours of ED discharge. Each return visit resulting in admission was independently reviewed by 3 physicians. Analysis was by descriptive statistics. Of 45 071 ED discharges, 4.1% returned within 72 hours; 0.96% returned for related reasons and were admitted to wards (91.2%), intensive care units (6.5%), or operating rooms (1.2%). Management was acceptable in 92.6%, suboptimal in 7.4%. Admissions were illness (94.9%), patient (1.6%), and physician related (3.5%). Almost all admissions within 72 hours after ED discharge are illness related, including all intensive care unit admissions and the majority of operating room admissions. Deficiencies in ED care are rarely the reason for admission on return. ED return visits resulting in admission may not be reflective of ED quality of care.

Access to outpatient follow-up orthopedic care after pediatric emergency department visits: impact of implementation of a managed Medicaid program.

BACKGROUND The use of ondansetron in children with vomiting after a head injury has not been well studied. Concern about masking serious injury is a potential barrier to its use. OBJECTIVE The aim of this study was to evaluate the use of ondansetron in children with head injury and symptoms of vomiting in the pediatric emergency department (PED) and its effect on return rates and masking of more serious injuries. DESIGN/METHODS Visits to 2 PEDs from 2003 to 2010 with a diagnosis of head injury were evaluated retrospectively. Patients discharged home after a head computed tomography (CT) are the primary cohort for the study. A logistic regression model was used to analyze ondansetrons effects on the likelihood of return to the PED within 72 hours for persistent symptoms. A secondary analysis was performed on patients with a diagnoses of head injury who did not receive a head CT and were discharged. RESULTS A total of 6311 patients had a diagnosis of head injury, had a head CT performed, and were discharged from the PED. The use of ondansetron increased significantly from 3.7% in 2003 to 22% in 2010 (P < .001). After controlling for demographic/acuity differences, receiving ondansetron in the PED was associated with a lower likelihood of returning within 72 hours (0.49, 95% confidence interval [0.26-0.92]). In patients with head injury who did not have a head CT performed and were sent home, the use of ondansetron in the PED was not associated with an increased risk of missed diagnoses. CONCLUSION Ondansetron use in children with a CT scan who are dispositioned home is relatively safe, does not appear to mask any significant conditions, and significantly reduces return visits to the PED.

Improving Discharge Instructions in a Pediatric Emergency Department: Impact of a Quality Initiative

Objective: A Medicaid managed care (MMC) program was instituted regionally with the goal of improving quality and access to care for underserved populations. The purpose of this study was to determine whether the implementation of an MMC program has affected access to timely orthopedic follow-up care. Methods: All visits to 2 tertiary care pediatric emergency departments (PED) with a diagnosis of extremity fracture or dislocation were examined for a 5-month period after implementation of MMC and compared with the same periods during 2004 and 2005. Repeat visits for orthopedic concerns to the PED within 30 days of the initial fracture care were compared across the pre- and post-MMC periods. Results: Six thousand four hundred nine visits with a diagnosis ofextremity fracture or dislocation were identified (4110 in the two 5-month pre-MMC periods and 2299 in the 5-month post-MMC period). A total of 167 return visits for orthopedic concerns were identified in the pre-MMC period (4.0%) compared with 150 return visits in the post-MMC period (6.5%) (P < 0.001). Of these, 12 (7.2%) in the pre-MMC period and 55 (36.6%) in the post-MMC period were identified as related to the inability to access outpatient orthopedic follow-up (P < 0.001). In both periods, Medicaid patients were more likely to return to the PED for inability to access care, compared with privately insured patients (odds ratio [OR], 6.1; 95% confidence interval [CI], 3.54-10.32). Conclusions: After the implementation of a regional MMC program, patients were increasingly unable to access routine outpatient follow-up. This may shift additional cost and resource load to PED, while limiting access to vital services for medically vulnerable patients.

Medical director dilemmas.

Background Effective communication between physician and patient is essential to optimize care after discharge from the emergency department (ED). Written discharge care instructions (DCI) complement verbal instructions and have been shown to improve communication and patient management. In 2012, Centers for Medicare and Medicaid Services proposed a quality measure (OP-19) that assesses compliance with key elements considered essential for high-quality written DCI. Objective To evaluate the impact of a QI intervention on improving quality of written DCI in a pediatric emergency department (PED). Methods A QI initiative was conducted at a tertiary PED with greater than 60,000 annual visits. Based on Centers for Medicare and Medicaid Services OP-19 measure and group consensus, 8 elements were defined a priori as requisites for good quality DCI. These elements are:Customized noteExplanation of presenting complaint/diagnosisTest(s) performedTest(s) resultsNew medication(s)Reason for medication(s)Reasons to follow-upFollow-up physicians/specialty name Providers reviewed a random sample of DCI of patients. Proportion of DCI that had each element documented was compared between preintervention phase (PRE) and postintervention phase (POST). Results Three hundred twenty-nine DCI (PRE) and 1434 DCI (POST) were reviewed. The POST DCI showed statistically significant improvement for each of the 8 elements. The bundle measure (proportion containing all 8 elements) increased from 23% (PRE) to 79% (POST) (P < 0.001). Conclusions The ED DCI improved in all 8 elements after a QI intervention. A detailed DCI at ED discharge enhances the patients ability to comply with postdischarge treatment plan. Further studies are needed to evaluate the impact of improving DCI on ED return rates and other outcomes.