- Email: [email protected]
20 A Description of Pediatric Frequent Users of Emergency Department Resources
Research Forum Abstracts Conclusion: In this analysis based on two large multicenter prospective studies of ED airway management, We found that older age, use of RSI, and intubation by emergency physicians were the independent predictors of a higher first-pass success in chilren. Our findings should facilitate investigations to develop optimal airway management strategies in critically-ill children in the ED.
19
Children Hospitalized With Rhinovirus Bronchiolitis Have Asthma-Like Characteristics
Mansbach J, Clark S, Piedra P, Sullivan A, Espinola J, Camargo C, Jr./Boston Children’s Hospital, Boston, MA; Weill Cornell Medical College, New York City, NY; Baylor College of Medicine, Houston, TX; Massachusetts General Hospital, Boston, MA
Study objectives: Children with bronchiolitis are often considered a homogenous group, a view reinforced by the 2014 American Academy of Pediatrics bronchiolitis clinical practice guideline. Emerging evidence, however, suggests that bronchiolitis is actually a heterogeneous condition with different short-term and long-term outcomes. Our objective was to test the hypothesis that children hospitalized with rhinovirus (RV) bronchiolitis would be more likely than children with respiratory syncytial virus (RSV) bronchiolitis to have asthma-like characteristics (ie, prior wheezing, atopic characteristics, and more frequent treatment with corticosteroids). Methods: We performed a 16-center, prospective cohort study of hospitalized children age <2 years with an attending diagnosis of bronchiolitis. For 3 consecutive winters (November-March) from 2007-2010, researchers collected clinical data and nasopharyngeal aspirates, which were tested for 16 viruses by PCR. We focused this secondary analysis on RSV and RV, the two most common viruses causing severe bronchiolitis. We compared RSV (RSV alone or coinfection with any virus, including RV) to RV (RV alone or coinfection with any other non-RSV virus). Analysis used Chi Square and multivariable logistic regression. Results: Among the 2,207 enrolled children, there were 1,589 (72%) infected with RSV, including 287 children with RSV + RV coinfection. There were 277 (13%) children infected with RV, including 110 children coinfected with other viruses besides RSV. Compared to children with RSV, children with RV were more likely to be age >6 months (30% vs 58%, P < .001), to be male (58% vs 66%, P ¼ .02), to have a history of wheezing (19% vs 36%, P < .001), to have a history of eczema (14% vs 23%, P < .001), and to receive corticosteroids in both the emergency department and the hospital (7% vs 23%, P < .001). In a multivariable model controlling for age, sex, race, history of wheeze, and history of eczema, children hospitalized with RV were more likely to receive corticosteroids in both the ED and in the hospital (adjusted odds ratio 2.1; 95% CI 1.4- 3.2). Results did not materially change in sensitivity analyses comparing different combinations of viruses, including RSV-only, RV-only, and RSV without RV coinfection or when restricting to children age <1 year. Conclusions: In a multicenter, multiyear, prospective cohort of US children hospitalized with bronchiolitis we found that children with RV bronchiolitis have similar characteristics to older children with asthma (eg, history of wheezing and history of eczema) including more frequent treatment with corticosteroids. We suggest that future research focus on identifying children age <2 years with bronchiolitis who may have short-term and/or long-term benefits from medications currently used to treat older children with asthma.
20
A Description of Pediatric Frequent Users of Emergency Department Resources
Castillo EM, Chan TC, Vilke GM, Hsia RY, Ishimine P, Shah S, Kapoor K, Brennan JJ/ University of California, San Diego, CA; University of California, San Francisco, CA; Rady Children’s Hospital, San Diego, CA
Study Objectives: Health care reform efforts have focused on improving resource utilization among patients who are disproportionate utilizers of health care services, specifically frequent users of emergency departments (EDs). Most studies have focused on adult frequent users, but little is known about pediatric frequent users. The purpose of this study is to evaluate patient characteristics and patterns of use of pediatrics frequent users of ED resources to better target interventions to provide appropriate resources to these patients. Methods: We performed a multi-center retrospective longitudinal cohort study of all hospital ED visits to California in 2011 using non-public data from 324 licensed nonmilitary acute care hospitals. Visits without a valid patient identifier and patients who expired were excluded. Pediatric patients were defined as 1-17 years of age and age was categorized as 1-5, 6-12 and 13-17 years of age. Frequent users were defined as having 6 or more ED visits during the 12-month study period. We identified demographics and patterns of use, and used logistic regression to assess independent associations between demographic characteristics, payer, and diagnoses between occasional users and frequent users.
S8 Annals of Emergency Medicine
Results: During the study period there were 5,332,044 individual patients seen in area EDs resulting in a total of 9,436,955 visits. Of these, 704,585 (13.2% of all patients) were pediatric patients with 1,039,557 visits (11.0% of all visits). A total of 7,147 (1.0%) of the pediatric patients were identified as frequent users and were responsible for 54,038 (5.2%) visits. The percent of frequent users within the pediatric age groups were relatively consistent (1.0, 1.2, and 0.7% of patients and 5.2, 5.6, 3.6% of visits, respectively from ages 1-5, 6-12 and 13-17 years of age). Nearly half of frequent users were seen in more than one ED (45.8%) while the majority of non-frequent users were seen in only one hospital (94.6%). “Acute upper respiratory infection multiple sites” (ICD-9-CM¼465.x) was the most common primary diagnosis at visits for both groups (5.5% of occasional users and 6.2% of frequent users). In the regression model comparing frequent users to occasional users, leaving against medical advice (OR¼6.7, 95% CI¼6.1, 7.3), chronic pulmonary disease diagnosis (OR¼6.1, 95% CI¼5.8, 6.4), and psychiatric diagnosis (OR¼5.8, 95% CI¼5.3, 6.4) had the highest associations with being a frequent user. Conclusion: In this study of all 324 non-military licensed EDs in California, there was a high number of pediatric frequent users with a disproportionate number of ED visits. This initial study of pediatric frequent ED users highlights an important ED user cohort.
21
Streamlined Admission of Critically Ill Trauma Patients Reduced Emergency Department Length of Stay
Fuentes E, Ramly E, Kaafarani H, Filbin M, King D, DeMoya M, Brown D, Yeh DD, Velmahos G, Lee J/Massachusetts General Hospital, Boston, MA
Study Objectives: Boarding of patients in the emergency department (ED) leads to increased ED congestion, length of stay (LOS), increased use of limited resources, worse patient and family satisfaction and possibly worse patient outcomes. Starting April 2013, our Level 1 Trauma institution began a quality improvement project to decrease ED LOS among critically ill trauma patients requiring intensive care unit (ICU) admission. A multi-disciplinary team developed and approved a new process allowing critically ill trauma patients leaving the ED resuscitation for the CT scanner to then go directly to the ICU. Previous to this new process, patients would return to the ED resuscitation area for further workup and stabilization before ICU admission. Methods: Starting April 1, 2013, all adult trauma activations were consecutively screened for the study. Pre-determined data elements were collected by trained research fellows from admission until discharge. These patients were then matched 1:1 to patients in our trauma database based on mechanism of injury, age, and Injury Severity Score. Proportions were analyzed with Pearson’s Chi-square test for significance. Results: Sixty-eight adult trauma patients were included in the study, 39 undergoing the new process and 39 matched controls. Patients admitted to the ICU with the new process had a dramatic decrease in the median ED LOS by 62%, from 4.56 hours to 1.28 hours (P < .001). There were no identifiable changes in hospital LOS, ICU LOS, mortality, 28-day ventilator-free days, deep venous thrombosis, urinary tract infections, pulmonary embolisms, and wound infections. Conclusions: A new process to streamline admission for critically-ill trauma patients at our Level 1 Trauma center significantly decreased ED LOS without adverse outcomes.
22
Impact of Early Urine Specimen Collection on Emergency Department Time to Disposition
Jamali AM, Ramesh G, Sharafi M, Ditkoff J, Bahl A/William Beaumont Hospital, Royal Oak, MI; Michigan State University College of Human Medicine, East Lansing, MI
Study Objectives: To evaluate whether a triage initiated urine specimen collection process would decrease emergency department (ED) time to disposition. Methods: This IRB-approved prospective, randomized control study was implemented at a suburban Level one trauma center with greater than 120,000 ED visits per year. A convenience sample of patients was recruited over the span of two months. Non-ambulance patients 21 years and older, with chief complaint of abdominal pain, flank pain, pelvic pain, and urinary complaints were eligible participants. Subjects were randomized into the experimental or control group using an envelope system. The control group proceeded thru the treatment process in normal fashion with the visit beginning at the greeter desk and culminating in the treatment area. After physician evaluation and if necessary, requests for urine samples were initiated per routine care. Patients in the experimental group received a urinalysis packet including a cup at the greeter desk upon arrival to the ED. The greeter prompted patients to provide a urine sample in the triage restrooms. These patients then proceeded to the treatment areas with urine samples in hand. Urine samples were then sent for lab analysis after physician evaluation and order placement as needed.
Volume 66, no. 4s : October 2015
19
Children Hospitalized With Rhinovirus Bronchiolitis Have Asthma-Like Characteristics
Mansbach J, Clark S, Piedra P, Sullivan A, Espinola J, Camargo C, Jr./Boston Children’s Hospital, Boston, MA; Weill Cornell Medical College, New York City, NY; Baylor College of Medicine, Houston, TX; Massachusetts General Hospital, Boston, MA
Study objectives: Children with bronchiolitis are often considered a homogenous group, a view reinforced by the 2014 American Academy of Pediatrics bronchiolitis clinical practice guideline. Emerging evidence, however, suggests that bronchiolitis is actually a heterogeneous condition with different short-term and long-term outcomes. Our objective was to test the hypothesis that children hospitalized with rhinovirus (RV) bronchiolitis would be more likely than children with respiratory syncytial virus (RSV) bronchiolitis to have asthma-like characteristics (ie, prior wheezing, atopic characteristics, and more frequent treatment with corticosteroids). Methods: We performed a 16-center, prospective cohort study of hospitalized children age <2 years with an attending diagnosis of bronchiolitis. For 3 consecutive winters (November-March) from 2007-2010, researchers collected clinical data and nasopharyngeal aspirates, which were tested for 16 viruses by PCR. We focused this secondary analysis on RSV and RV, the two most common viruses causing severe bronchiolitis. We compared RSV (RSV alone or coinfection with any virus, including RV) to RV (RV alone or coinfection with any other non-RSV virus). Analysis used Chi Square and multivariable logistic regression. Results: Among the 2,207 enrolled children, there were 1,589 (72%) infected with RSV, including 287 children with RSV + RV coinfection. There were 277 (13%) children infected with RV, including 110 children coinfected with other viruses besides RSV. Compared to children with RSV, children with RV were more likely to be age >6 months (30% vs 58%, P < .001), to be male (58% vs 66%, P ¼ .02), to have a history of wheezing (19% vs 36%, P < .001), to have a history of eczema (14% vs 23%, P < .001), and to receive corticosteroids in both the emergency department and the hospital (7% vs 23%, P < .001). In a multivariable model controlling for age, sex, race, history of wheeze, and history of eczema, children hospitalized with RV were more likely to receive corticosteroids in both the ED and in the hospital (adjusted odds ratio 2.1; 95% CI 1.4- 3.2). Results did not materially change in sensitivity analyses comparing different combinations of viruses, including RSV-only, RV-only, and RSV without RV coinfection or when restricting to children age <1 year. Conclusions: In a multicenter, multiyear, prospective cohort of US children hospitalized with bronchiolitis we found that children with RV bronchiolitis have similar characteristics to older children with asthma (eg, history of wheezing and history of eczema) including more frequent treatment with corticosteroids. We suggest that future research focus on identifying children age <2 years with bronchiolitis who may have short-term and/or long-term benefits from medications currently used to treat older children with asthma.
20
A Description of Pediatric Frequent Users of Emergency Department Resources
Castillo EM, Chan TC, Vilke GM, Hsia RY, Ishimine P, Shah S, Kapoor K, Brennan JJ/ University of California, San Diego, CA; University of California, San Francisco, CA; Rady Children’s Hospital, San Diego, CA
Study Objectives: Health care reform efforts have focused on improving resource utilization among patients who are disproportionate utilizers of health care services, specifically frequent users of emergency departments (EDs). Most studies have focused on adult frequent users, but little is known about pediatric frequent users. The purpose of this study is to evaluate patient characteristics and patterns of use of pediatrics frequent users of ED resources to better target interventions to provide appropriate resources to these patients. Methods: We performed a multi-center retrospective longitudinal cohort study of all hospital ED visits to California in 2011 using non-public data from 324 licensed nonmilitary acute care hospitals. Visits without a valid patient identifier and patients who expired were excluded. Pediatric patients were defined as 1-17 years of age and age was categorized as 1-5, 6-12 and 13-17 years of age. Frequent users were defined as having 6 or more ED visits during the 12-month study period. We identified demographics and patterns of use, and used logistic regression to assess independent associations between demographic characteristics, payer, and diagnoses between occasional users and frequent users.
S8 Annals of Emergency Medicine
Results: During the study period there were 5,332,044 individual patients seen in area EDs resulting in a total of 9,436,955 visits. Of these, 704,585 (13.2% of all patients) were pediatric patients with 1,039,557 visits (11.0% of all visits). A total of 7,147 (1.0%) of the pediatric patients were identified as frequent users and were responsible for 54,038 (5.2%) visits. The percent of frequent users within the pediatric age groups were relatively consistent (1.0, 1.2, and 0.7% of patients and 5.2, 5.6, 3.6% of visits, respectively from ages 1-5, 6-12 and 13-17 years of age). Nearly half of frequent users were seen in more than one ED (45.8%) while the majority of non-frequent users were seen in only one hospital (94.6%). “Acute upper respiratory infection multiple sites” (ICD-9-CM¼465.x) was the most common primary diagnosis at visits for both groups (5.5% of occasional users and 6.2% of frequent users). In the regression model comparing frequent users to occasional users, leaving against medical advice (OR¼6.7, 95% CI¼6.1, 7.3), chronic pulmonary disease diagnosis (OR¼6.1, 95% CI¼5.8, 6.4), and psychiatric diagnosis (OR¼5.8, 95% CI¼5.3, 6.4) had the highest associations with being a frequent user. Conclusion: In this study of all 324 non-military licensed EDs in California, there was a high number of pediatric frequent users with a disproportionate number of ED visits. This initial study of pediatric frequent ED users highlights an important ED user cohort.
21
Streamlined Admission of Critically Ill Trauma Patients Reduced Emergency Department Length of Stay
Fuentes E, Ramly E, Kaafarani H, Filbin M, King D, DeMoya M, Brown D, Yeh DD, Velmahos G, Lee J/Massachusetts General Hospital, Boston, MA
Study Objectives: Boarding of patients in the emergency department (ED) leads to increased ED congestion, length of stay (LOS), increased use of limited resources, worse patient and family satisfaction and possibly worse patient outcomes. Starting April 2013, our Level 1 Trauma institution began a quality improvement project to decrease ED LOS among critically ill trauma patients requiring intensive care unit (ICU) admission. A multi-disciplinary team developed and approved a new process allowing critically ill trauma patients leaving the ED resuscitation for the CT scanner to then go directly to the ICU. Previous to this new process, patients would return to the ED resuscitation area for further workup and stabilization before ICU admission. Methods: Starting April 1, 2013, all adult trauma activations were consecutively screened for the study. Pre-determined data elements were collected by trained research fellows from admission until discharge. These patients were then matched 1:1 to patients in our trauma database based on mechanism of injury, age, and Injury Severity Score. Proportions were analyzed with Pearson’s Chi-square test for significance. Results: Sixty-eight adult trauma patients were included in the study, 39 undergoing the new process and 39 matched controls. Patients admitted to the ICU with the new process had a dramatic decrease in the median ED LOS by 62%, from 4.56 hours to 1.28 hours (P < .001). There were no identifiable changes in hospital LOS, ICU LOS, mortality, 28-day ventilator-free days, deep venous thrombosis, urinary tract infections, pulmonary embolisms, and wound infections. Conclusions: A new process to streamline admission for critically-ill trauma patients at our Level 1 Trauma center significantly decreased ED LOS without adverse outcomes.
22
Impact of Early Urine Specimen Collection on Emergency Department Time to Disposition
Jamali AM, Ramesh G, Sharafi M, Ditkoff J, Bahl A/William Beaumont Hospital, Royal Oak, MI; Michigan State University College of Human Medicine, East Lansing, MI
Study Objectives: To evaluate whether a triage initiated urine specimen collection process would decrease emergency department (ED) time to disposition. Methods: This IRB-approved prospective, randomized control study was implemented at a suburban Level one trauma center with greater than 120,000 ED visits per year. A convenience sample of patients was recruited over the span of two months. Non-ambulance patients 21 years and older, with chief complaint of abdominal pain, flank pain, pelvic pain, and urinary complaints were eligible participants. Subjects were randomized into the experimental or control group using an envelope system. The control group proceeded thru the treatment process in normal fashion with the visit beginning at the greeter desk and culminating in the treatment area. After physician evaluation and if necessary, requests for urine samples were initiated per routine care. Patients in the experimental group received a urinalysis packet including a cup at the greeter desk upon arrival to the ED. The greeter prompted patients to provide a urine sample in the triage restrooms. These patients then proceeded to the treatment areas with urine samples in hand. Urine samples were then sent for lab analysis after physician evaluation and order placement as needed.
Volume 66, no. 4s : October 2015