Siraj Amanullah

Increasing Computed Tomography Use for Patients With Appendicitis and Discrepancies in Pain Management Between Adults and Children: An Analysis of the NHAMCS

STUDY OBJECTIVE Using a national sample of emergency department (ED) visits, we aim to describe use of CBC, computed tomography (CT), and pain medication among ED visits in which appendicitis was diagnosed. We describe use trends over time and identify use differences between adults and children. METHODS The ED component of the National Hospital Ambulatory Medical Care Survey was analyzed for 1992 through 2006, comprising a sample of 447,011 visits (representing an estimated total of approximately 1.5 billion visits), from which a sample of 1,088 patients (representing an estimated 3.7 million patients) received a diagnosis of appendicitis. The frequency of CBC and CT use and frequency of pain medication administration were determined. Survey-adjusted regression analyses were used to determine the probability of a patient receiving CBC, CT, or pain medication. Use was compared between adults and children. RESULTS During the course of the study, from 1996 to 2006, the percentage of patients with appendicitis who received a CT scan increased from 6.3% (95% confidence interval [CI] 0% to 15.3%) to 69% (95% CI 55.5% to 81.7%) for adults and from 0% to 59.8% (95% CI 31.6% to 87.9%) for children. CBC use for adults increased from 77.2% (95% CI 62.9% to 91.5%) to 92.8% (95% CI 85.8% to 99.7%) and decreased from 89.1% (95% CI 74.9% to 100.0%) to 68.4% (95% CI 41.9% to 94.9%) for children. The use of pain medications increased from 24.8% (95% CI 11.3% to 38.4%) to 69.9% (95% CI 56.7% to 83.1%) for adults and from 27.2% (95% CI 5.7% to 48.8%) to 42.8% (95% CI 18.1% to 67.5%) for children. The proportion of children who received parenteral narcotics (13.7% [95% CI 9.3% to 18.0%]) was less than that of adults (23% [95% CI 18.9% to 27.1%]). CONCLUSION CT use has increased for patients with appendicitis over time, and CBC use remains high. There has been an increase in analgesic administration, but more than half of all patients with appendicitis had not received pain medication over the course of the entire study period. Children received fewer parenteral narcotics than adults and appeared to be preferentially treated with nonparenteral nonnarcotic analgesics.

Heads Up Communication Is Key in School Nurses’ Preparedness for Facilitating “Return to Learn” Following Concussion

Background. Recent literature advocates for a school academic team, including school nurses, to support concussed students’ return to the classroom. This study aimed to assess the current understanding and practices of a sample of school nurses regarding the concept of “return to learn” in concussed students. Methods. Cross-sectional survey of New England school nurses. Results. The greatest barrier to the school nurses’ functioning within the academic rehabilitation team for students with concussion was “inadequate communication with the provider that diagnosed the concussion” (73%). Of the 151 school nurses surveyed, 19% felt that they did not have the training necessary for this role. Other barriers included “inadequate concussion training” (38%) and “inadequate time necessary to care for a student with concussion” (30%). Conclusions. By identifying specific gaps in knowledge and challenges at the school level, these results inform interdisciplinary medical teams about the importance of educating and facilitating effective “return to learn” academic plans.

Analysis of blood tests in the emergency department of a tertiary care hospital

There is ample evidence that many investigations sent from the accident and emergency department are inappropriate, thus affecting the quality of patient care. A study was designed to address this issue in the emergency department of a tertiary care hospital of a large city. A prospective cross-sectional study was carried out during the 3-month period 1 December 1996 to 28 February 1997. A set of guidelines was used to assess the appropriateness of different blood tests for the initial assessment of the patients presenting with common clinical conditions, although any investigation could be done if considered important for patient management. All other blood tests were considered inappropriate. A total of 6401 patients were seen in the emergency department and 14 300 blood tests were done on 3529 patients with diagnoses covered by the guidelines. Of these 62.2% were found to be inappropriate. Of the total 22 655 investigations done on all the 6401 patients seen, only 3.8% influenced the diagnosis, 3.0% influenced patient care in the emergency department, and 4.0% influenced the decision to admit or not. Amylase and arterial blood gases were found to be the most appropriate investigations. Analysis of reasons for unnecessary use of emergency tests suggested that improving supervision, decreasing the utilization of the emergency department as a phlebotomy service for the hospital, and abolition of routine blood tests would help to improve patient care.

The use of local anesthetic techniques for closed forearm fracture reduction in children: a survey of academic pediatric emergency departments.

Background: Although local anesthetic techniques (hematoma blocks, nerve blocks, intravenous regional anesthesia) for forearm fracture reduction are well described and commonly used in adults, it is unclear how often these techniques are used in children. Objective: To characterize the use of local anesthesia for pediatric closed forearm fracture reduction by pediatric and orthopedic physicians practicing in teaching hospitals in Canada and the United States. Methods: An on-line survey targeting physicians practicing in hospitals with pediatric emergency medicine (PEM) fellowships in Canada and the United States was sent to the PEM fellowship director and orthopedic department head at each hospital. Results: Sixty-three orthopedic surgeons and 69 PEM physicians were invited to participate in the survey, and 63% responded of all invited participants. All respondents routinely use sedation for forearm fracture reduction. Local anesthesia is used by 78% of respondents (55% rarely, 28% sometimes, and 17% frequently). Hematoma blocks are used by 92% of respondents who use local anesthesia; 20% use Bier blocks, and 2% use cubital blocks. Among respondents who never use local anesthesia, all believe that sufficient analgesia is obtained from procedural sedation alone, and 35% believe that local anesthesia is ineffective. Conclusions: Local anesthetic techniques are used only occasionally by those surveyed. More studies examining the use of local anesthesia for forearm fractures in children are necessary to evaluate the need for more widespread use.

Emergency Department Visits Resulting From Intentional Injury In and Out of School

BACKGROUND AND OBJECTIVE: Previous studies have reported concerning numbers of injuries to children in the school setting. The objective was to understand temporal and demographic trends in intentional injuries in the school setting and to compare these with intentional injuries outside the school setting. METHODS: Data from the National Electronic Injury Surveillance System–All Injury Program from 2001 to 2008 were analyzed to assess emergency department visits (EDVs) after an intentional injury. RESULTS: There were an estimated 7 397 301 total EDVs due to injuries sustained at school from 2001 to 2008. Of these, an estimated 736 014 (10%) were reported as intentional (range: 8.5%–10.7% for the study time period). The overall risk of an EDV after an intentional injury in school was 2.33 (95% confidence interval [CI]: 1.93–2.82) when compared with an EDV after an intentional injury outside the school setting. For intentional injury–related EDVs originating in the school setting, multivariate regression identified several demographic risk factors: 10- to 14-year-old (odds ratio [OR]: 1.58; 95% CI: 1.10–2.27) and 15- to 19-year-old (OR: 1.69; 95% CI: 1.01–2.82) age group, black (OR: 4.14; 95% CI: 2.94–5.83) and American Indian (OR: 2.48; 95% CI: 2.06–2.99) race, and Hispanic ethnicity (OR: 3.67; 95% CI: 2.02–6.69). The odds of hospitalization resulting from intentional injury–related EDV compared with unintentional injury–related EDVs was 2.01 (95% CI: 1.50–2.69) in the school setting. These odds were found to be 5.85 (95% CI: 4.76–7.19) in the outside school setting. CONCLUSIONS: The findings of this study suggest a need for additional prevention strategies addressing school-based intentional injuries.

Hematologic emergencies in the pediatric emergency room

The complete blood count (CBC) describes the three hematopoietic lineages (i.e., the erythrocytes, leukocytes, and platelets), and it is an essential diagnostic component in numerous clinical situations. The pediatric CBC and hematologic problems in children may significantly differ from that of adults. In this article, special features of pediatric hematologic emergencies are highlighted.

Presentation to Either the Pediatric Emergency Department or Primary Care Clinic for Acute Illness: The Caregivers’ Perspective

Objectives This study aimed to understand and compare caregivers’ perceptions of and attitudes toward care received in a primary care clinic (PCC) versus that received in the pediatric emergency department (PED) as well as the reasons for selecting either location to receive care for their child. Methods Surveys were administered to caregivers of children who receive their primary care at the same location who presented for a nonurgent sick visit to either the PCC or PED during regular PCC hours. Results One hundred fifty-one caregivers in the PCC and 83 in the PED completed the survey. Compared with caregivers who brought their child to the PED, those who presented to the PCC were more likely to report that the child had been sick for more than 2 days (P < 0.001), indicate that the child could wait more than 3 hours to be seen (P < 0.001), have called the PCC for advice (odds ratio [OR], 5.2; 95% confidence interval [CI], 2.9–9.2), have spoken with a nurse (OR, 3.7; 95% CI, 2.0–6.7), be satisfied with their phone call to the PCC (OR, 12.2; 95% CI, 6.4–23.1), and report that they could easily get in touch with the PCC (OR, 3.6; 95% CI, 1.8–7.3). Most caregivers who went to the PCC felt that it was more convenient (98.6%) and they would be seen more quickly (95.8%). Conclusions Although all children had the same medical home, caregivers who presented to the PCC were more likely to have called the clinic, spoken with a nurse, and reported greater satisfaction with the PCC than those who brought their child to the PED.

Differences in presentation and management of pediatric facial lacerations by type of health insurance

Introduction Limited data are available regarding differences in presentation and management of pediatric emergency department (PED) patients based on insurance status. The objective of the study was to assess the difference in management of pediatric facial lacerations based on medical insurance status. Methods We conducted a retrospective cohort study with universal sampling of patients with facial lacerations who were treated in an urban PED (45K visits/year) over a one-year period. Demographic features and injury characteristics for patients with commercial (private) insurance and those with Medicaid or Medicare (public) insurance were compared. Results Of 1235 children included in the study, 667 (54%) had private insurance and 485 (39%) had public insurance. The two groups did not differ in age or gender, arrival by ambulance, location of injury occurrence, mechanism of injury, part of face involved, length or depth of laceration, use of local anesthetic, or method of repair but differed in acuity assigned at triage. Patients with public insurance were found less likely to have subspecialty consultation in bivariable (OR=0.41, 95% CI [0.24–0.68]) and multivariable logistic regression analyses (OR=0.45, 95% CI [0.25–0.78]). Patients with public insurance received procedural sedation significantly less often than those with private insurance (OR=0.48, 95% CI [0.29–0.76]). This difference was not substantiated in multivariable models (OR=0.74, 95% CI [0.40–1.31]). Conclusion Patients with public insurance received less subspecialty consultation compared to privately insured patients despite a similarity in the presentation and characteristics of their facial lacerations. The reasons for these disparities require further investigation.

Emergency Department Visits Owing to Intentional and Unintentional Traumatic Brain Injury among Infants in the United States: A Population-Based Assessment

Objective To examine national trends of emergency department (ED) visits owing to traumatic brain injury (TBI) among infants (age <12 months), specifically in the context of intentional and unintentional mechanisms. Study design National Electronic Injury Surveillance System—All Injury Program data documenting nonfatal ED visits from 2003 to 2012 were analyzed. TBI was defined as ED visits resulting in a diagnosis of concussion, or fracture, or internal injury of the head. Intentional and unintentional injury mechanisms were compared using multivariable models. Joinpoint regression was used to identify significant time trends. Results TBI‐related ED visits (estimated n = 713 124) accounted for 28% of all injury‐related ED visits by infants in the US, yielding an average annual rate of 1722 TBI‐related ED visits per 100 000 infants. Trend analysis showed an annual increase of 9.48% in the rate of TBI‐related ED visits over 10 years (P < .05). For these visits, an estimated 701 757 (98.4%) were attributed to unintentional mechanisms and 11 367 (1.6%) to intentional mechanisms. Unintentional TBI‐related ED visit rates increased by 9.52% annually (P < .05) and the rates of intentional TBI were relatively stable from 2003 to 2012. Infants with intentional TBI were more likely to be admitted (aOR, 11.44; 95% CI, 3.02‐21.75) compared with those with unintentional TBI. Conclusions The rate of TBI‐related ED visits in infants increased primarily owing to unintentional mechanisms and intentional TBI‐related ED visits remained stable over the decade. Improved strategies to reduce both intentional and unintentional injuries in infants are required.

The Inverse Relationship between Digital Media Exposure and Childhood Flourishing

Objective To describe the relationship between digital media exposure (DME) and parental perception of childhood flourishing, or overall positive well‐being. It is hypothesized that there is an inverse association between parent‐reported measures of childhood flourishing and increasing daily DME. Study design Parental responses for children ages 6‐17 years (N = 64 464) from the 2011‐2012 National Survey of Childrens Health were analyzed. Average weekday DME that was not school work related was categorized in 2‐hour intervals: 0 to <2, 2 to < 4, 4 to < 6, and ≥6 hours. Bivariate analyses and logistic regression models were used to examine the relationship between DME and parent‐reported frequency of 5 childhood flourishing markers: completing homework, caring about academics, finishing tasks, staying calm when challenged, and showing interest in learning. Results Only 31% reported <2 hours of weekday DME. For the remaining children, daily DME was 2 to <4 hours (36%), 4 to <6 hours (17%), or ≥6 hours (17%). In a model adjusted for age, sex, race, poverty level, primary language spoken at home, and highest maternal education level, there was a dose‐dependent decrease in the odds of demonstrating all 5 markers of flourishing as weekday DME increased (test for trend for each outcome P < .001). In stratified analyses, this relationship held true regardless of the childs age group, sex, or poverty level. Conclusion This study provides evidence that, among school‐aged children, increasing weekday DME has an inverse dose‐dependent relationship with multiple childhood flourishing markers.