Steven E. Krug

Language Barriers and Resource Utilization in a Pediatric Emergency Department

Background. Although an inability to speak English is recognized as an obstacle to health care in the United States, it is unclear how clinicians alter their diagnostic approach when confronted with a language barrier (LB). Objective. To determine if a LB between families and their emergency department (ED) physician was associated with a difference in diagnostic testing and length of stay in the ED. Design. Prospective cohort study. Methods. This study prospectively assessed clinical status and care provided to patients who presented to a pediatric ED from September 1997 through December 1997. Patients included were 2 months to 10 years of age, not chronically ill, and had a presenting temperature ≥38.5°C or complained of vomiting, diarrhea, or decreased oral intake. Examining physicians determined study eligibility and recorded the Yale Observation Score if the patient was <3 years old, and whether there was a LB between the physician and the family. Standard hospital charges were applied for each visit to any of the 22 commonly ordered tests. Comparisons of total charges were made among groups using Mann-Whitney U tests. Analysis of covariance was used to evaluate predictors of total charges and length of ED stay. Results. Data were obtained about 2467 patients. A total of 286 families (12%) did not speak English, resulting in a LB for the physician in 209 cases (8.5%). LB patients were much more likely to be Hispanic (88% vs 49%), and less likely to be commercially insured (19% vs 30%). These patients were slightly younger (mean 31 months vs 36 months), but had similar acuity, triage vital signs, and Yale Observation Score (when applicable). In cases in which a LB existed, mean test charges were significantly higher:

The pediatrician and disaster preparedness

145 versus

Hospital treatment of asthma: lack of benefit from theophylline given in addition to nebulized albuterol and intravenously administered corticosteroid**

104, and ED stays were significantly longer: 165 minutes versus 137 minutes. In an analysis of covariance model including race/ethnicity, insurance status, physician training level, attending physician, urgent care setting, triage category, age, and vital signs, the presence of a LB accounted for a

Management of pediatric trauma

38 increase in charges for testing and a 20 minute longer ED stay. Conclusion. Despite controlling for multiple factors, the presence of a physician–family LB was associated with a higher rate of resource utilization for diagnostic studies and increased ED visit times. Additional study is recommended to explore the reasons for these differences and ways to provide care more efficiently to non-English-speaking patients. language barriers, resource utilization, test ordering.

Emergency department overcrowding and children.

For decades, emergency planning for natural disasters, public health emergencies, workplace accidents, and other calamities has been the responsibility of government agencies on all levels and certain nongovernment organizations such as the American Red Cross. In the case of terrorism, however, entirely new approaches to emergency planning are under development for a variety of reasons. Terrorism preparedness is a highly specific component of general emergency preparedness. In addition to the unique pediatric issues involved in general emergency preparedness, terrorism preparedness must consider several additional issues, including the unique vulnerabilities of children to various agents as well as the limited availability of age- and weight-appropriate antidotes and treatments. Although children may respond more rapidly to therapeutic intervention, they are at the same time more susceptible to various agents and conditions and more likely to deteriorate if they are not monitored carefully. This article is designed to provide an overview of key issues for the pediatrician with respect to disaster, terrorism, and public health emergency preparedness. It is not intended to be a complete compendium of didactic content but rather offers an approach to what pediatricians need to know and how pediatricians must lend their expertise to enhance preparedness in every community. To become fully and optimally prepared, pediatricians need to become familiar with these key areas of emergency preparedness: unique aspects of children related to terrorism and other disasters; terrorism preparedness; mental health vulnerabilities and development of resiliency; managing family concerns about terrorism and disaster preparedness; office-based preparedness; hospital preparedness; community, government, and public health preparedness; and advocating for children and families in preparedness planning.

EVALUATION OF THE INFANT WITH FEVER WITHOUT SOURCE: AN EVIDENCE BASED APPROACH

STUDY OBJECTIVE To determine the efficacy of theophylline when given in addition to nebulized albuterol and intravenously administered corticosteroid to children hospitalized with mild to moderate asthma. DESIGN Randomized, prospective, placebo-controlled, double-blind trial. SETTING Tertiary-care childrens hospital. PATIENTS Twenty-nine patients with asthma between the ages of 2 and 16 years completed the study. The treatment and placebo groups were similar in age, gender, race, illness severity, and emergency department treatment. INTERVENTIONS All patients received intravenously administered methylprednisolone and nebulized albuterol. The treatment group received intravenous theophylline therapy and the placebo group dextrose in water. When intravenously administered medications were discontinued, therapy continued with oral administration of theophylline (or placebo) and of prednisone. MEASUREMENTS AND MAIN RESULTS Twice-daily assessments of clinical asthma symptoms were made by using a scoring system consisting of respiratory rate, inspiratory/expiratory ratio, wheeze, and accessory muscle use. Time required to reach study discharge criteria (asthma score < or = 2) (30.4 +/- 16.8 vs 27.0 +/- 10.3 hours; p = 0.51) and the rate of improvement of the clinical asthma score (-0.10 +/- 0.05 unit/hr vs -0.11 +/- 0.09 unit/hr; p = 0.88) were not significantly different between the theophylline and placebo groups. The number of albuterol aerosol treatments required and the adverse effects experienced were not significantly different between groups. CONCLUSION When the combination of systemically administered corticosteroid and inhaled albuterol is used in the treatment of children hospitalized with mild to moderate asthma, addition of theophylline may not be justified.

Patient safety in the pediatric emergency care setting

Injury is the number 1 killer of children in the United States. In 2004, injury accounted for 59.5% of all deaths in children younger than 18 years. The financial burden to society of children who survive childhood injury with disability continues to be enormous. The entire process of managing childhood injury is complex and varies by region. Only the comprehensive cooperation of a broadly diverse group of people will have a significant effect on improving the care and outcome of injured children. This statement has been endorsed by the American Association of Critical-Care Nurses, American College of Emergency Physicians, American College of Surgeons, American Pediatric Surgical Association, National Association of Childrens Hospitals and Related Institutions, National Association of State EMS Officials, and Society of Critical Care Medicine.

Pediatric emergency department utilization habits: a consumer survey.

Emergency department (ED) overcrowding has been a serious issue on the national agenda for the past 2 decades and is rapidly becoming an increasingly significant problem for children. The goal of this report is to focus on the issues of overcrowding that directly impact children. Our findings reveal that although overcrowding seems to affect children in ways similar to those of adults, there are several important ways in which they differ. Recent reports document that more than 90% of academic emergency medicine EDs are overcrowded. Although inner-city, urban, and university hospitals have historically been the first to feel the brunt of overcrowding, community and suburban EDs are now also being affected. The overwhelming majority of children (92%) are seen in general community EDs, with only a minority (less than 10%) treated in dedicated pediatric EDs. With the exception of patients older than 65 years, children have higher visit rates than any other age group. Children may be at particularly increased risk for medical errors because of their inherent variability in size and the need for age-specific and weight-based dosing. We strongly recommend that pediatric issues be actively included in all future aspects of research and policy planning issues related to ED overcrowding. These include the development of triage protocols, clinical guidelines, research proposals, and computerized data monitoring systems.

Policy statement - Consent for emergency medical services for children and adolescents

The infant with fever without an obvious source upon physical examination offers a challenging clinical problem. A combination of detailed history, physical examination, and selected laboratory tests allows the clinician to discern which infants are at lower risk for bacterial illness. Implications for management and future research are discussed herein.

Contribution of Routine Pulse Oximetry to Evaluation and Management of Patients With Respiratory Illness in a Pediatric Emergency Department

Patient safety is a priority for all health care professionals, including those who work in emergency care. Unique aspects of pediatric care may increase the risk of medical error and harm to patients, especially in the emergency care setting. Although errors can happen despite the best human efforts, given the right set of circumstances, health care professionals must work proactively to improve safety in the pediatric emergency care system. Specific recommendations to improve pediatric patient safety in the emergency department are provided in this policy statement.