- Email: [email protected]
296 Characteristics of Pediatric Emergency Department Patients Requiring Transfer
Research Forum Abstracts not be definitive. The use of magnetic resonance imaging (MRI) for diagnosis of pediatric appendicitis is relatively new, but several small studies suggest good sensitivity and specificity. The objective of this study is to further evaluate the test characteristics of MRI for the diagnosis of appendicitis in pediatric patients. Methods: This is an interim analysis. All abdominal, pelvis, or right lower quadrant MRIs done on pediatric patients aged 3-21 years from July 2010 to June 2011 were evaluated retrospectively for an indication referable to potential appendicitis. MRI findings were compared to patient outcome as detailed in hospital records (for admitted patients) or on phone follow-up (for patients discharged home from the emergency department). If patient was not reachable by phone, subsequent visits were reviewed for mention of appendicitis or appendectomy. Patients with a normal appendix identified by MRI and those with no appendix identified but no changes indicative of appendicitis are considered to have a negative MRI for the purposes of this analysis. MRI results and patient outcomes were collected by independent reviewers after a brief training session to improve blinding. Results: Eighty-eight patients were identified (mean age 15.5 years, 41% male). Of these 60% were admitted. Eleven patients were excluded (lost to follow-up, incarcerated, MRI cancelled), leaving 77 for the analysis. Of these, 12 ultimately were diagnosed with appendicitis. Fifty-five MRIs were negative with no missed cases of appendicitis (sensitivity: 100%; 95% CI: 70%-100%). Fourteen patients had a positive MRI: 12 true positives, 1 patient who was clinically determined not to have appendicitis, and 1 tubo-ovarian abscess (specificity: 96%; 95% CI: 87%-99%). The remaining 8 scans were either indicative of an alternate pathology (6) or equivocal (2); none of these patients had appendicitis. Conclusion: Though limited by availability, MRI may be an excellent tool to diagnose appendicitis in the pediatric population. However, a larger sample is needed to substantiate the high sensitivity found in our patients.
296
Characteristics of Pediatric Emergency Department Patients Requiring Transfer
Barata IA, Mahmooth Z, Bradburn K, D’Angelo J, Raio C, Schneider S, Ward MF/North Shore University Hospital, Manhasset, NY
Background: There are over 31 million yearly pediatric (18 years old) visits to emergency departments (EDs) in the US. There are currently 250 children’s hospitals (under 5% of all hospitals) and 213 trauma centers with pediatric specific capabilities in the US. These hospitals have become the referral centers for pediatric transfers from general ED. Understanding the characteristics of pediatric patients requiring transfer may result in better resource allocation and improved care. Study Objective: The objective of this study is to describe the characteristics of pediatric patients requiring a transfer to a specialty hospital including demographics (age, sex, insurance and household income), initial hospital location (metropolitan or non-metropolitan), and having an injury/poisoning or psychiatric diagnosis. Methods: This study reviewed the Nationwide ED (NEDS) database for pediatric patients (18 years) who were transferred in 2010 from the general ED to another short-term hospital, skilled nursing or intermediate care facility, or home health care. The NEDS uses the Healthcare Cost and Utilization Project (HCUP) State Emergency Department Databases (SEDD) and the State Inpatient Databases (SID). The NEDS database includes inpatient and ED information from 28 states. We used a multivariate logistic regression model to calculate the adjusted odds of being transferred based on different patient characteristics. Results: In the 2010 NEDS database of 28 States, there were over 25 million ED visits. Of those 6.1 million were for pediatric patients comprising approximately a quarter of the total visits to the ED; about 2% (or 104,353) resulted in a transfer. The mean age of children transferred was 7.7 years. Female pediatric patients had a 15% lower chance of being transferred (OR: 0.85, P<.001). Medicare patients compared to private insurance, including HMOS, had 27% greater odds of being transferred (OR: 1.27, P¼.002), but selfpay had 19% lower likelihood of being transferred (OR: 0.81, P<.001). There was no statistically significant difference in transfer rates between private insurance and Medicaid and those with no pay. Using the median household income for the patient’s zip code, patients in the second, third, and fourth quartile had 10, 30, and 35% higher odds of being transferred respectively compared to those in the first quartile. The odds of being transferred were inversely related to wealth. Overall odds of transfer related to place of residence were 26% greater for non-metropolitan areas than metropolitan areas (OR: 1.26, P<.001). Patients with a first listed diagnosis of injury had 8% higher odds of being transferred (OR: 1.08, P<.001) and those with a first listed psychiatric diagnosis were 12 times as likely to be transferred (OR: 12.08, P<.001) as compared to all other patients. Conclusion: Pediatric patients comprise approximately a quarter of all patients seen in ED in the US. Most of these patients are evaluated/treated at a general ED and a
Volume 64, no. 4s : October 2014
small percentage are transferred to a specialty hospital. The possibility of being transferred is inversely related to wealth. Pediatric patients in non-metropolitan areas are more likely to be transferred. Patients with a psychiatric diagnosis are much more likely to be transferred than any other patient type. These are important considerations for ED to take into account to prepare to take care of pediatric patients.
297
A Randomized Controlled Trial of 2% Lidocaine Gel Compared to Current Standard of Care in Infants Undergoing Urinary Catheterization
Castelo M, Li J, Taddio A, Lepore N, Lim R, Reider M, Poonai N/Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada; Schulich School of Medicine & Dentistry, Western University, London, ON, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada; Western University, London, ON, Canada
Study Objectives: Urinary catheterization is the preferred method of obtaining a sterile urine specimen from a young child and is performed frequently in the emergency department (ED). However, this procedure can be a source of distress not only for the child but also for caregivers and health care professionals. Evidence suggests that the provision of analgesia in the ED is sorely lacking. Therefore, it is imperative that we strive to develop evidence-based approaches for minimizing discomfort during common, painful procedures. This study was undertaken to determine whether topical and intraurethral lidocaine is superior to the standard of care for relieving pain in children undergoing urinary catheterization in the ED. Methods: This prospective, single blind trial randomized children from birth to 24 months of age who required urethral catheterization in the ED via pharmacy-controlled block design. Children either received the standard of care (no analgesic) or both topical and intraurethral 2% lidocaine gel, using a weight-based protocol. The primary outcome variable was the pre-post difference between groups on the Neonatal Facial Coding System (NFCS). Three variables were scored using the NFCS – eye-squeeze, brow furrowing, and lengthening of the naso-labial furrow. Results: A total of 126 participants were included in the analysis, with 61 and 65 participants randomized to the standard of care and lidocaine groups, respectively. There was a mean age of 4.2 months (range: 4 days, 16 months) and 8.3 months (range: 7.5 days, 23 months) in the standard of care and lidocaine groups, respectively. The standard of care group consisted of 54.1% males and 45.9% females, and the lidocaine group consisted of 46.2% males and 53.8% females. There was a significantly smaller pre-post difference in eye-squeeze scores (P¼.02) among patients in the standard of care group (mean delta¼0.43, 0.45 SD, 95% CI: 0.31, 0.54) compared to the lidocaine group (mean delta¼0.27, 0.39 SD, 95% CI: 0.17, 0.37). Additionally, there was a significant decrease in the total time infants displayed a lengthened naso-labial furrow (P¼.03) between the standard of care group (mean delta¼-0.03, 1.80 SD, 95% CI: -0.49, 0.43) and the lidocaine group (mean delta¼0.35, 2.73 SD, 95% CI: -1.03, 0.33). There was no significant difference found between the standard of care group (mean delta¼0.44, 0.49 SD, 95% CI: 0.32, 0.57) and the lidocaine group (mean delta¼0.40, 0.42 SD, 95% CI: 0.30, 0.51) for the brow-bulge variable (P¼.37). Conclusion: Two of the three NFCS variables studied showed significant decreases between the standard of care and lidocaine groups. Results of this study suggest that the provision of analgesia by a simple non-invasive protocol can significantly reduce procedural pain associated with catheterization in children. This study should be considered by clinicians attempting to practice an evidence-based approach to alleviating pain during procedures in the ED.
298
Infants With Fractures in the Pediatric Emergency Department: Are We Considering Child Physical Abuse?
Lavin LR, Penrod C, Estrada C, Arnold D, Xu M, Saville B, Lowen D/Vanderbilt University, Nashville, TN
Background: An estimated quarter of infant fractures are considered to be due to child physical abuse (PA). Recognition of PA is important to avoid further morbidity and mortality. The American Academy of Pediatrics recommends providers consider non-accidental injury in any infant presenting with fractures. There is limited knowledge regarding how frequently pediatric emergency department (PED) clinicians consider child abuse in infants with fractures. Study Objective: We sought to estimate the percentage of infants with fractures for whom PA was considered, and to examine characteristics that are associated with consideration of PA.
Annals of Emergency Medicine S105
296
Characteristics of Pediatric Emergency Department Patients Requiring Transfer
Barata IA, Mahmooth Z, Bradburn K, D’Angelo J, Raio C, Schneider S, Ward MF/North Shore University Hospital, Manhasset, NY
Background: There are over 31 million yearly pediatric (18 years old) visits to emergency departments (EDs) in the US. There are currently 250 children’s hospitals (under 5% of all hospitals) and 213 trauma centers with pediatric specific capabilities in the US. These hospitals have become the referral centers for pediatric transfers from general ED. Understanding the characteristics of pediatric patients requiring transfer may result in better resource allocation and improved care. Study Objective: The objective of this study is to describe the characteristics of pediatric patients requiring a transfer to a specialty hospital including demographics (age, sex, insurance and household income), initial hospital location (metropolitan or non-metropolitan), and having an injury/poisoning or psychiatric diagnosis. Methods: This study reviewed the Nationwide ED (NEDS) database for pediatric patients (18 years) who were transferred in 2010 from the general ED to another short-term hospital, skilled nursing or intermediate care facility, or home health care. The NEDS uses the Healthcare Cost and Utilization Project (HCUP) State Emergency Department Databases (SEDD) and the State Inpatient Databases (SID). The NEDS database includes inpatient and ED information from 28 states. We used a multivariate logistic regression model to calculate the adjusted odds of being transferred based on different patient characteristics. Results: In the 2010 NEDS database of 28 States, there were over 25 million ED visits. Of those 6.1 million were for pediatric patients comprising approximately a quarter of the total visits to the ED; about 2% (or 104,353) resulted in a transfer. The mean age of children transferred was 7.7 years. Female pediatric patients had a 15% lower chance of being transferred (OR: 0.85, P<.001). Medicare patients compared to private insurance, including HMOS, had 27% greater odds of being transferred (OR: 1.27, P¼.002), but selfpay had 19% lower likelihood of being transferred (OR: 0.81, P<.001). There was no statistically significant difference in transfer rates between private insurance and Medicaid and those with no pay. Using the median household income for the patient’s zip code, patients in the second, third, and fourth quartile had 10, 30, and 35% higher odds of being transferred respectively compared to those in the first quartile. The odds of being transferred were inversely related to wealth. Overall odds of transfer related to place of residence were 26% greater for non-metropolitan areas than metropolitan areas (OR: 1.26, P<.001). Patients with a first listed diagnosis of injury had 8% higher odds of being transferred (OR: 1.08, P<.001) and those with a first listed psychiatric diagnosis were 12 times as likely to be transferred (OR: 12.08, P<.001) as compared to all other patients. Conclusion: Pediatric patients comprise approximately a quarter of all patients seen in ED in the US. Most of these patients are evaluated/treated at a general ED and a
Volume 64, no. 4s : October 2014
small percentage are transferred to a specialty hospital. The possibility of being transferred is inversely related to wealth. Pediatric patients in non-metropolitan areas are more likely to be transferred. Patients with a psychiatric diagnosis are much more likely to be transferred than any other patient type. These are important considerations for ED to take into account to prepare to take care of pediatric patients.
297
A Randomized Controlled Trial of 2% Lidocaine Gel Compared to Current Standard of Care in Infants Undergoing Urinary Catheterization
Castelo M, Li J, Taddio A, Lepore N, Lim R, Reider M, Poonai N/Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada; Schulich School of Medicine & Dentistry, Western University, London, ON, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada; Western University, London, ON, Canada
Study Objectives: Urinary catheterization is the preferred method of obtaining a sterile urine specimen from a young child and is performed frequently in the emergency department (ED). However, this procedure can be a source of distress not only for the child but also for caregivers and health care professionals. Evidence suggests that the provision of analgesia in the ED is sorely lacking. Therefore, it is imperative that we strive to develop evidence-based approaches for minimizing discomfort during common, painful procedures. This study was undertaken to determine whether topical and intraurethral lidocaine is superior to the standard of care for relieving pain in children undergoing urinary catheterization in the ED. Methods: This prospective, single blind trial randomized children from birth to 24 months of age who required urethral catheterization in the ED via pharmacy-controlled block design. Children either received the standard of care (no analgesic) or both topical and intraurethral 2% lidocaine gel, using a weight-based protocol. The primary outcome variable was the pre-post difference between groups on the Neonatal Facial Coding System (NFCS). Three variables were scored using the NFCS – eye-squeeze, brow furrowing, and lengthening of the naso-labial furrow. Results: A total of 126 participants were included in the analysis, with 61 and 65 participants randomized to the standard of care and lidocaine groups, respectively. There was a mean age of 4.2 months (range: 4 days, 16 months) and 8.3 months (range: 7.5 days, 23 months) in the standard of care and lidocaine groups, respectively. The standard of care group consisted of 54.1% males and 45.9% females, and the lidocaine group consisted of 46.2% males and 53.8% females. There was a significantly smaller pre-post difference in eye-squeeze scores (P¼.02) among patients in the standard of care group (mean delta¼0.43, 0.45 SD, 95% CI: 0.31, 0.54) compared to the lidocaine group (mean delta¼0.27, 0.39 SD, 95% CI: 0.17, 0.37). Additionally, there was a significant decrease in the total time infants displayed a lengthened naso-labial furrow (P¼.03) between the standard of care group (mean delta¼-0.03, 1.80 SD, 95% CI: -0.49, 0.43) and the lidocaine group (mean delta¼0.35, 2.73 SD, 95% CI: -1.03, 0.33). There was no significant difference found between the standard of care group (mean delta¼0.44, 0.49 SD, 95% CI: 0.32, 0.57) and the lidocaine group (mean delta¼0.40, 0.42 SD, 95% CI: 0.30, 0.51) for the brow-bulge variable (P¼.37). Conclusion: Two of the three NFCS variables studied showed significant decreases between the standard of care and lidocaine groups. Results of this study suggest that the provision of analgesia by a simple non-invasive protocol can significantly reduce procedural pain associated with catheterization in children. This study should be considered by clinicians attempting to practice an evidence-based approach to alleviating pain during procedures in the ED.
298
Infants With Fractures in the Pediatric Emergency Department: Are We Considering Child Physical Abuse?
Lavin LR, Penrod C, Estrada C, Arnold D, Xu M, Saville B, Lowen D/Vanderbilt University, Nashville, TN
Background: An estimated quarter of infant fractures are considered to be due to child physical abuse (PA). Recognition of PA is important to avoid further morbidity and mortality. The American Academy of Pediatrics recommends providers consider non-accidental injury in any infant presenting with fractures. There is limited knowledge regarding how frequently pediatric emergency department (PED) clinicians consider child abuse in infants with fractures. Study Objective: We sought to estimate the percentage of infants with fractures for whom PA was considered, and to examine characteristics that are associated with consideration of PA.
Annals of Emergency Medicine S105