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3 In a Population of Patients Presenting to a Pediatric Emergency Department, Is Receiving a Text Message Reminder Associated With Increased Follow-up Compliance after Discharge?
Research Forum Abstracts population of school-aged children (ages 7-12) demonstrated moderate correlation and excellent reliability. The objective of this study was to determine correlation of 3 commonly used pain scales: A 100-mm unhatched horizontal Visual Analogue Scale (VAS), the Wong Baker Pain FACES Rating scale (WBS) and the Charleston Pediatric Pain Pictures (CPPP), in young children (ages 3-6). We hypothesized that pain ratings between the scales would not be highly correlated (⬎0.7). Methods: Prospective observational. Setting: University-based, suburban pediatric ED. Subjects: Patients, age 3-6 years, presenting with acute pain. Measures: Patients reported pain severity using VAS, WBS and CPPP. Analysis: Analysis of variance was used to compare VAS scores across the WBS and CPPP categories. Spearman’s correlations were used to measure agreement across scales. Results: One hundred and eighteen children were enrolled; 48% female. Pain was attributed to trauma/injury in 57%. The median duration of pain was 12 hours (IQR 3-48). The most common pain locations were; abdomen (27%), head/scalp (24%), lower extremity (20%), upper extremity (14%). Thirty-five were unable to complete the VAS. The mean VAS increased across WBS and CPPP categories; both p⬍0.001. ANOVA demonstrated significant differences in mean VAS across WBS and CPPP categories; both p⬍0.01. Agreement () between pain scales was poor; WBS/VAS ⫽ 0.46 (95% CI: 0.27 to 0.61), CPPP/ VAS ⫽ 0.35 (95% CI: 0.15 to 0.53), and CPPP/WBS ⫽ 0.38 (95% CI: 0.21 to 0.52). Correlation among the pain scales did not differ by sex, grade, pain location or cause of pain. Conclusion: The correlation between the 3 pain scales was poor in young children. Our findings suggest that these scales are not interchangeable.
3
In a Population of Patients Presenting to a Pediatric Emergency Department, Is Receiving a Text Message Reminder Associated With Increased Follow-up Compliance after Discharge?
Salinero EA, Cramm K, Papa L/Orlando Health, Orlando, FL
Study Objectives: Compliance with recommended follow-up from the pediatric emergency department (ED) has been shown to be poor. This study evaluated whether a text message reminder to the caregivers after discharge from the pediatric ED improved compliance with recommended primary care follow-up. Methods: This was a blinded randomized control trial conducted at a Level 1 pediatric trauma center. The intervention was a text message sent to the caregiver within 24 hours of discharge from the pediatric ED reminding them to follow up with their primary care doctor. Patients were eligible if the caregiver had text message capability on their cellular phones, were currently established patients of the organization’s Pediatric faculty practice, were discharged home from the pediatric ED, and were referred for follow-up within 1 week of discharge by the pediatric emergency physicians. After informed consent, pediatric patients were randomized to either an intervention group (text message appointment reminder) or a control group (standard treatment with no reminder). The patient, treating physician, and primary care outpatient center were blinded to the group assignment. Enrollment occurred 24 hours per day and 7 days per week. Results: There were 123 patients enrolled in the study, 62 patients were randomized to the control group (standard treatment) and 61 patients were randomized to the intervention group (text message reminder). Overall, the average age of participants was 2.2 years (SD 2.8), 72 (58%) were male, 51 (42%) were female and 29 (24%) presented to the pediatric ED on a weekend. There were 35 (28%) patients who completed the recommended follow-up and the average time from pediatric ED discharge to follow-up was 6 days (SD 4.2)[range 0-17 days]. There was no significant difference in follow-up in the standard treatment group 19/ 62 (31%) versus the text message intervention group 16/61 (26%) (P⫽0.69). When we assessed other variables we found that caregivers of younger children were more likely to follow-up as recommended by the pediatric ED physician with a mean age of 1.3 (SD 2.0) [range 0.8-9.1] years in those who followed-up versus 2.6 (SD 3.0) [range 0.08-15.3] years in those who did not follow-up (P⫽0.02). Conclusion: In this randomized controlled study, a text message reminder to caregivers did not improve compliance for pediatric ED patients. However, caregivers of younger children were more likely to complete follow-up as recommended by the pediatric ED physician compared to caregivers of older children.
S2 Annals of Emergency Medicine
4
Intern Self-assessment and Prediction of Lumbar Puncture Success
Reinhardt JC, Grossman D, Kunkov S, Thode H/Stony Brook University, Stony Brook, NY
Study Objective: To examine pediatric and emergency medicine interns’ selfassessment in performing infant lumbar puncture and how that self-assessment predicts clinical success of lumbar puncture. To determine the agreement between intern self-assessment and supervisor assessment of infant lumbar puncture performance on the simulator and infants. Methods: Prospective cohort study of infant (⬍1yo) lumbar puncture performed by interns with Just-in-Time (JIT) refreshers. Eligibility: Pediatric/emergency medicine interns at participating institutions. Mastery training included a video demonstrating how to perform infant lumbar puncture and then simulation training. Infant lumbar punctures performed were preceded by a JIT refresher. A questionnaire including a validated global skills assessment instrument was completed by interns/ supervisors after the JIT refresher and lumbar puncture. Results: Three hundred eighty-six JIT encounters performed at 35 institutions (313 pediatric and 14 emergency medicine interns, 16 nurse practitioner/psychiatry, and 43 missing). Data was analyzed from the 327 encounters by pediatric and emergency medicine interns. The overall level of skills self-assessment after JIT was competent/proficient in 109 encounters (33.3%). JIT encounters by emergency medicine versus pediatric interns showed similar percentages of these levels of selfassessment (42.9% versus 32.9%, p⫽.44). The overall levels of skills self-assessment after lumbar puncture were reported to be competent/proficient in 109 encounters (33.3%). Supervising physicians rated interns’ skills as competent/proficient in 39.4% of the recorded JIT encounters. There was a moderate correlation between interns’ self-assessment of their skills and supervising physicians’ assessment of their skills after JIT and after actual lumbar puncture (Kappa⫽0.42 and 0.46, respectively). Supervising physicians were able to correctly predict successful lumbar puncture in 42.8% (n⫽119) and unsuccessful lumbar puncture in 80% (n⫽12) of the cases (p⫽.08). 71.4% (10/14) lumbar punctures performed by emergency medicine interns were successful, compared to 38.0% (119/313) by pediatric interns (p⫽.01). Conclusion: The success rate of lumbar puncture performed by pediatric interns was low, with a concordance between the pediatric interns’ self-assessment of their lumbar puncture skills and the success rate of the lumbar puncture. Despite similarly low levels of self-assessment of their lumbar puncture skills, higher lumbar puncture success rate was observed among emergency medicine interns. Supervising physicians’ ability to predict successful lumbar puncture by interns was low.
5
Protecting Those Who Cannot Protect Themselves
Peraino A, Donaldson D, Shah P, Munafo S, Thomas T, Palomba K, Shaqiri B, Anderson W, Bastani A/Troy Beaumont Hospital, Troy, MI
Study Objectives: When pediatric patients present to the emergency department (ED) status post head trauma, emergency physicians are trained to have a high level of suspicion for the possibility of abuse. If abuse is not identified at the initial visit, a resultant increase in morbidity and mortality has been described. Pre-verbal (age ⬍2 years) patients, due to their small physical size, early developmental status, and need for constant care, are a particularly vulnerable population. Our objectives were to describe the prevalence of suspected/confirmed child abuse in pre-verbal patients presenting to the ED with isolated minor head trauma. Furthermore, our objective was to evaluate this cohort for another year from the index visit to identify any trauma-related ED visits and concerns regarding missed child abuse. Methods: We conducted a secondary analysis of a standardized chart review of all children under the age of 2 who presented to our community hospital and received a head CT (HCT) for trauma between Jan 1, 2010 and Dec 31, 2010. Utilizing a preformed data extraction sheet, the clinical outcome of the index visit and assessment for suspected/confirmed child abuse was recorded. Additionally, patients within this cohort who had any subsequent or prior trauma-related ED visits within a year of the index visit were also identified. The clinical outcome of the secondary trauma-related ED visits and assessments regarding the possibility of suspected/confirmed child abuse were again documented. Our primary outcome measure was the prevalence of suspected/confirmed child abuse in pre-verbal pediatric head injury patients. Our secondary outcomes were the prevalence and clinical outcomes of the subsequent trauma-related ED visit in this cohort as well as the prevalence of suspected/confirmed child abuse not identified on the index visit. Data was analyzed using descriptive statistics; 95% confidence intervals were calculated around proportions using the modified Wald method.
Volume , . : October
3
In a Population of Patients Presenting to a Pediatric Emergency Department, Is Receiving a Text Message Reminder Associated With Increased Follow-up Compliance after Discharge?
Salinero EA, Cramm K, Papa L/Orlando Health, Orlando, FL
Study Objectives: Compliance with recommended follow-up from the pediatric emergency department (ED) has been shown to be poor. This study evaluated whether a text message reminder to the caregivers after discharge from the pediatric ED improved compliance with recommended primary care follow-up. Methods: This was a blinded randomized control trial conducted at a Level 1 pediatric trauma center. The intervention was a text message sent to the caregiver within 24 hours of discharge from the pediatric ED reminding them to follow up with their primary care doctor. Patients were eligible if the caregiver had text message capability on their cellular phones, were currently established patients of the organization’s Pediatric faculty practice, were discharged home from the pediatric ED, and were referred for follow-up within 1 week of discharge by the pediatric emergency physicians. After informed consent, pediatric patients were randomized to either an intervention group (text message appointment reminder) or a control group (standard treatment with no reminder). The patient, treating physician, and primary care outpatient center were blinded to the group assignment. Enrollment occurred 24 hours per day and 7 days per week. Results: There were 123 patients enrolled in the study, 62 patients were randomized to the control group (standard treatment) and 61 patients were randomized to the intervention group (text message reminder). Overall, the average age of participants was 2.2 years (SD 2.8), 72 (58%) were male, 51 (42%) were female and 29 (24%) presented to the pediatric ED on a weekend. There were 35 (28%) patients who completed the recommended follow-up and the average time from pediatric ED discharge to follow-up was 6 days (SD 4.2)[range 0-17 days]. There was no significant difference in follow-up in the standard treatment group 19/ 62 (31%) versus the text message intervention group 16/61 (26%) (P⫽0.69). When we assessed other variables we found that caregivers of younger children were more likely to follow-up as recommended by the pediatric ED physician with a mean age of 1.3 (SD 2.0) [range 0.8-9.1] years in those who followed-up versus 2.6 (SD 3.0) [range 0.08-15.3] years in those who did not follow-up (P⫽0.02). Conclusion: In this randomized controlled study, a text message reminder to caregivers did not improve compliance for pediatric ED patients. However, caregivers of younger children were more likely to complete follow-up as recommended by the pediatric ED physician compared to caregivers of older children.
S2 Annals of Emergency Medicine
4
Intern Self-assessment and Prediction of Lumbar Puncture Success
Reinhardt JC, Grossman D, Kunkov S, Thode H/Stony Brook University, Stony Brook, NY
Study Objective: To examine pediatric and emergency medicine interns’ selfassessment in performing infant lumbar puncture and how that self-assessment predicts clinical success of lumbar puncture. To determine the agreement between intern self-assessment and supervisor assessment of infant lumbar puncture performance on the simulator and infants. Methods: Prospective cohort study of infant (⬍1yo) lumbar puncture performed by interns with Just-in-Time (JIT) refreshers. Eligibility: Pediatric/emergency medicine interns at participating institutions. Mastery training included a video demonstrating how to perform infant lumbar puncture and then simulation training. Infant lumbar punctures performed were preceded by a JIT refresher. A questionnaire including a validated global skills assessment instrument was completed by interns/ supervisors after the JIT refresher and lumbar puncture. Results: Three hundred eighty-six JIT encounters performed at 35 institutions (313 pediatric and 14 emergency medicine interns, 16 nurse practitioner/psychiatry, and 43 missing). Data was analyzed from the 327 encounters by pediatric and emergency medicine interns. The overall level of skills self-assessment after JIT was competent/proficient in 109 encounters (33.3%). JIT encounters by emergency medicine versus pediatric interns showed similar percentages of these levels of selfassessment (42.9% versus 32.9%, p⫽.44). The overall levels of skills self-assessment after lumbar puncture were reported to be competent/proficient in 109 encounters (33.3%). Supervising physicians rated interns’ skills as competent/proficient in 39.4% of the recorded JIT encounters. There was a moderate correlation between interns’ self-assessment of their skills and supervising physicians’ assessment of their skills after JIT and after actual lumbar puncture (Kappa⫽0.42 and 0.46, respectively). Supervising physicians were able to correctly predict successful lumbar puncture in 42.8% (n⫽119) and unsuccessful lumbar puncture in 80% (n⫽12) of the cases (p⫽.08). 71.4% (10/14) lumbar punctures performed by emergency medicine interns were successful, compared to 38.0% (119/313) by pediatric interns (p⫽.01). Conclusion: The success rate of lumbar puncture performed by pediatric interns was low, with a concordance between the pediatric interns’ self-assessment of their lumbar puncture skills and the success rate of the lumbar puncture. Despite similarly low levels of self-assessment of their lumbar puncture skills, higher lumbar puncture success rate was observed among emergency medicine interns. Supervising physicians’ ability to predict successful lumbar puncture by interns was low.
5
Protecting Those Who Cannot Protect Themselves
Peraino A, Donaldson D, Shah P, Munafo S, Thomas T, Palomba K, Shaqiri B, Anderson W, Bastani A/Troy Beaumont Hospital, Troy, MI
Study Objectives: When pediatric patients present to the emergency department (ED) status post head trauma, emergency physicians are trained to have a high level of suspicion for the possibility of abuse. If abuse is not identified at the initial visit, a resultant increase in morbidity and mortality has been described. Pre-verbal (age ⬍2 years) patients, due to their small physical size, early developmental status, and need for constant care, are a particularly vulnerable population. Our objectives were to describe the prevalence of suspected/confirmed child abuse in pre-verbal patients presenting to the ED with isolated minor head trauma. Furthermore, our objective was to evaluate this cohort for another year from the index visit to identify any trauma-related ED visits and concerns regarding missed child abuse. Methods: We conducted a secondary analysis of a standardized chart review of all children under the age of 2 who presented to our community hospital and received a head CT (HCT) for trauma between Jan 1, 2010 and Dec 31, 2010. Utilizing a preformed data extraction sheet, the clinical outcome of the index visit and assessment for suspected/confirmed child abuse was recorded. Additionally, patients within this cohort who had any subsequent or prior trauma-related ED visits within a year of the index visit were also identified. The clinical outcome of the secondary trauma-related ED visits and assessments regarding the possibility of suspected/confirmed child abuse were again documented. Our primary outcome measure was the prevalence of suspected/confirmed child abuse in pre-verbal pediatric head injury patients. Our secondary outcomes were the prevalence and clinical outcomes of the subsequent trauma-related ED visit in this cohort as well as the prevalence of suspected/confirmed child abuse not identified on the index visit. Data was analyzed using descriptive statistics; 95% confidence intervals were calculated around proportions using the modified Wald method.
Volume , . : October