- Email: [email protected]
397 Pediatric Triage Decisionmaking in a Large-Scale Pediatric Disaster
Research Forum Abstracts 25.3% and 53.8% respectively. The total percentage of performed CT with the group visited from 2012 to 2013 was 25.5%. The percentage of patients who only performed CT or ultrasound was 18.9% and 74.5%, respectively. The negative appendectomy rate was 13.2% in the 2010-2011 visited group, but was 8% in the 2012-2013 visited group. (P ¼ .19) There were no significant differences in hospital days, rate of drainage insertion, duration of drainage in situ, and perforation. There was a significant difference only in the duration of usage of antibiotics which was longer in the 2012-2013 visited group compared with 6.94(3.41) in the 20102011 visited group. Conclusion: The proportion of patients who underwent ultrasound without a CT scan was increased and the rate of performed CT scan was decreased. The rate of patients performing both imaging studies was decreased. However, negative appendectomy rate and complication rate were not significantly different statistically, except for the duration of antibiotics use.
395
Predictors of Successful Age 12-Month Follow-Up in a Multicenter Study of Infants With Severe Bronchiolitis
Wu V, Abo-Sido N, Espinola JA, Tierney CN, Sullivan AF, Camargo CA, Jr./ Massachusetts General Hospital, Boston, MA
Study Objectives: Obtaining participant follow-up is critical to the success of prospective cohort studies. Identifying characteristics associated with successful followup can help inform efforts to retain participants in the study. We examined the characteristics that predict successful telephone follow-up with parents of acutely ill children at age 12 months. Methods: We analyzed data from a 17-center, prospective cohort study of infants (age <1 year) hospitalized with bronchiolitis. Infants were enrolled during three consecutive winter seasons (November to April) in 2011 to 2014. Site investigators collected baseline interview and medical record data during the index hospitalization. We called parents at 6-month intervals (based on the child’s age) after discharge to assess the child’s respiratory problems, subsequent emergency department visits or hospitalizations, and other factors related to recurrent wheeze development. Respondents were coded as unreachable after 28 days of unsuccessful efforts to reach the parent. All children whose parents we attempted to contact for the age 12-month follow-up interview were included in the present analysis. To identify predictors of age 12-month follow-up completion, we used chi-square, Fisher’s exact test, and multivariable logistic regression clustered by site. Two-tailed P < .05 was considered statistically significant. Results: Among 918 children, median age at enrollment was 3 months (interquartile range 2-6). Of these, 798 (87%) completed the age 12-month interview. In unadjusted analyses, age 12-month follow-up completion was more likely if the child was female, had private health insurance, an annual household income $60,000, and from the Northeast, Midwest, or West regions (all P < .05). Follow-up was less likely among non-Hispanic black children, and Hispanics (all P < .05). In adjusted analyses, follow-up completion remained more likely among parents of female children (odds ratio [OR] 1.52; 95% confidence interval [CI] 1.04-2.23; P ¼ .03), those with an annual household income $60,000 (OR 1.63; 95% CI 1.01-2.64; P ¼ .045) and, compared to the South, those in the Northeast (OR 1.91; 95% CI 1.223.01; P ¼ .005), Midwest (OR 1.97; 95% CI 1.23-3.14; P ¼ .005) and West (OR 1.64; 95% CI 1.01-2.66; P ¼ .046). Additionally, compared to non-Hispanic white children, non-Hispanic blacks (OR 0.53; 95% CI 0.35-0.82; P ¼ .004) and Hispanics (OR 0.63; 95% CI 0.43-0.91; P ¼ .014) were less likely to complete the age 12-month follow-up interview. Conclusion: Female sex, white race, greater annual household income, and residing in the Northeast, Midwest, or West predicted successful age 12-month follow-up. These findings suggest potential benefits from developing and implementing better follow-up methods, particularly for families of participants who are male, minorities, or from the South.
396
Predicting Flow in the Pediatric Emergency Department: Are Holidays Lighter?
Agoritsas K, Krinsky-Deiner M, Chao J, Sinert R/SUNY Downstate Medical Center, Brooklyn, NY
Study Objectives: One of the major aspects of emergency department (ED) operations is matching patient demand with staffing and resources to ensure
Volume 66, no. 4s : October 2015
efficient throughput. It is common belief among providers that there are fewer visits on holidays in an ED. The objective was to determine the effect of national holidays on patient volume in an urban pediatric emergency department (PED). Methods: Login dates and times were obtained for all patient visits to an urban PED between July 1, 2006 and June 30, 2013. Visits were coded for the day of the week, tour, season, and whether they occurred on a holiday or non-holiday. Comparisons between the median number of visits on holidays vs. non-holidays by season, days of the week and tours were performed. Additional comparisons of the five Monday holidays (Martin Luther King Day, Washington’s Birthday, Memorial Day, Labor Day, and Columbus Day), as well as New Year’s, Thanksgiving, and Christmas Days to non-holidays were also performed. Group comparisons were performed via Mann-Whitney U tests and Kruskal-Wallis tests (alpha¼ 0.05, 2 tails). Results: There were 101 holiday and 2,456 non-holiday days, for a total of 2,557 days between July 1, 2006 and June 30, 2013. There were 223,677 total visits, with an average yearly census of 31,954. Volume peaked on Mondays versus the other days of the week (99 vs 76-91). The summer season demonstrated the fewest visits per day relative to the other seasons (74 vs 89-91; P < .001). Compared to non-holiday Thursdays within the fall season, there were fewer visits on Thanksgiving (81 vs 92; P < .001). Compared to nonholidays within the winter season there were fewer visits on Christmas (72 vs 90; P ¼ .031). There was no significant difference between numbers of visits on Monday holidays with same day of week non-holidays within their seasons. Tour 1 (12am-8am) demonstrated more patients on holidays compared to nonholidays during the winter (16 vs 12; P < .001), spring (21 vs 12; P < .001), and summer (18 vs 11; P < .001). Tour 2 (8am-4pm) did not demonstrate any significant difference in number of visits for any of the seasons. Tour 3 (4pm12am) demonstrated fewer patients on holidays vs. non-holidays during the fall (33 vs 38; P ¼ .027), winter (34 vs 38; P ¼ .001), and summer (31 vs 34; P ¼ .017). Conclusion: There are fewer patient visits on Thanksgiving and Christmas, as well as during late afternoon/evening on several other holidays. Our findings suggest potential for adjustments in staffing and resource planning for a PED.
397
Pediatric Triage Decisionmaking in a Large-Scale Pediatric Disaster
DeGeorge L, Glick R, Ackerman A, Wu Y/Virginia Tech Carilion School of Medicine, Roanoke, VA; Carilion Clinic, Roanoke, VA
Background: Children are profoundly vulnerable during a disaster or mass casualty event and yet are an often neglected group in emergency planning. Although triage is a critical task to be completed whenever there is a surge of patients, research on current triage algorithms have not included which group of providers is best able to perform the task of patient triage. Study Objective: The primary goal of this study is to determine if health care professionals not board certified in pediatric care make the same triage decisions in a mass casualty event with a high level of confidence compared to providers trained in the field of pediatrics. A secondary goal is to analyze key patient characteristics and clinical factors that are used by providers in assigning pediatric triage classifications. Methods: This is a survey-based study conducted at Carilion Roanoke Memorial Hospital (CRMH) using 11 case scenarios. Subjects were recruited from the departments of pediatrics and emergency medicine and asked to read each case and assign a triage classification based on the JumpSTART triage algorithm with each color designation assigned a numerical value- green¼ 1, yellow¼2, red¼3, and black¼4. They were also asked to rate their level of confidence using a Likert Scale ranging from 1 to 5 with 1 being not at all confident and 5 representing very confident. Finally, they were asked to answer whether the patient needed to be seen at a children’s hospital and to state in 1-2 sentences the key elements in the case on which they based their answers to each question. An extended version of Kappa coefficient was used to compare inter-rater agreement. Mean values for reported confidence scores were determined. Categorization and qualitative analysis of clinical factors cited was also undertaken. Results: Determination of Kappa coefficient revealed fair agreement amongst raters from the pediatric department (kappa¼ 0.38), moderate agreement within the emergency medicine department (kappa¼ 0.44), and moderate agreement across all raters (kappa¼ 0.42). Both departments reported high confidence in their triage decisions with mean confidence scores of 4.37 (pediatric department) and
Annals of Emergency Medicine S143
Research Forum Abstracts 4.54 (EM department). Clinical factors cited in decision making fell into 1 of 4 categories: vital signs (cited 75 times), physical exam findings (170), mechanism of injury/history of present illness (126), or anticipation of the patient’s future needs (58). Conclusions: Fair to moderate agreement across raters suggests the need for increased training of providers on the use of the JumpSTART triage algorithm. This is supported by analysis of key clinical factors used in decisionmaking which suggest the algorithm was not consistently and appropriately applied by providers. Lack of agreement also indicates deficiencies in the triage system itself. High confidence levels from both groups aid in emergency planning by indicating either group of providers is capable of the task of triage in a large scale disaster. Additional work surveying providers under conditions that more intentionally simulate a mass casualty event and including providers from other departments can further this research.
398
Application of the National Emergency XRadiography Utilization Study Criteria and the Canadian C-spine Rule Among Children Aged 8 to 17 Years in the Emergency Department: A Retrospective Review
Pepin LC, Bressler S, Brenner C, Avarello JT, Johnson AA, Prince JM, Bank MA, Dlugacz Y, Silverman RA/Hofstra North Shore-LIJ School of Medicine, Hempstead, NY; North Shore-LIJ Health System, New Hyde Park, NY; Krasnoff Institute of Quality Management, New Hyde Park, NY
Study Objectives: Clinical rules have been developed to identify acute trauma patients who require imaging of the cervical spine. While the computed tomography (CT) scan is highly sensitive for detecting cervical spine injury (CSI), unnecessary ionizing radiation is of concern, especially in children. The clinical rules have been more extensively tested in adults; however, there is support in the literature for National Emergency X-Radiography Utilization Study criteria (NEXUS) to reliably detect injury in children over 7 years old. The Canadian Cspine Rule (CCR) has also been considered but unlike the NEXUS, validation testing has not been performed in this pediatric age group. Our goal is to determine the number of cervical CT scans that could have potentially been avoided had NEXUS and CCR been applied to children aged 8 to 17 years with acute trauma. Methods: We conducted a retrospective chart review of children aged 8 to 17 years who received a cervical CT scan for blunt trauma in the emergency departments (ED) of an adult and pediatric level I trauma center from January 2010 to November 2013. Clinical variables deemed equivalent to NEXUS and CCR were established prior to chart review. Reviewers were blinded from CT results, and the need for CT scan based on risk of CSI was determined using NEXUS and CCR criteria. Based on chart review, the CT scan was classified as indicated or not indicated. If clinical data was missing, then the rule could not be applied and this was noted. Data abstraction reproducibility of the recorded findings were confirmed through independent review of an enriched sample including all patients with abnormal CT findings and 50 randomly selected charts. Results: Four hundred thirty-two patients aged 8 to 17 years received a cervical CT scan for acute trauma with an average age of 14 years and 270 (63%) males. A total of 2.5% (11/432) had abnormal cervical CT scan findings reported, and 1% (4/ 432) of the children had clinically significant CSI requiring intervention. The injuries requiring intervention included C4, C5 compression fracture; C5, C6 avulsion fracture; C1/C2 rotary subluxation; and C7 fracture. NEXUS indicated imaging in 70% (303), did not indicate imaging in 24% (102), and could not be applied in 6% (27). CCR indicated imaging in 58% (250), did not indicate imaging in 16% (68), and could not be applied in 26% (114) due to missing range of motion documentation (ROM). 89 of the 114 children with missing ROM were discharged directly from the ED. Had normal ROM been documented in these patients, those not indicated for imaging by CCR would have risen to 36%. None of the patients with clinically significant CSI were categorized as “not indicated” for imaging with either the NEXUS or CCR tools. Conclusion: Application of the NEXUS and CCR would have reduced cervical spine CT imaging in older children aged 8 to17 years. While no serious injury was missed with either tool, a limitation of our study is the low number of serious spinal injuries. A limitation of the current medical literature includes the use of retrospective chart reviews rather than prospective validation of the rules. Given the importance of
S144 Annals of Emergency Medicine
avoiding unnecessary CT imaging in children, more work is needed to determine the sensitivity of these tools in this older pediatric age group.
399 400
Withdrawn
Emergency Department Visits for Mental Illness: Evaluation of Patterns and Risk Factors of Return Visits from Claim Database: 2005-2013
Lee S, Johnson R, Sangaralingham L, Herrin J, Campbell RL/Mayo Clinic Health System, Mankato, MN; Mayo Clinic, Rochester, MN; Yale University, New Haven, CT
Study Objectives: Mental health-related visits account for up to 12 percent of all emergency department (ED) visits in the United States. EDs are frequently used for the initial evaluation of mental health emergencies and return visits to the hospital may represent avoidable health care utilization. The primary objective was to determine risk factors associated with return ED visits or inpatient admissions following an initial mental health-related ED visit. Methods: A retrospective study was performed using Optum Labs Data Warehouse, a large nationally representative database containing administrative claims data on privately insured and Medicare Advantage enrollees. We identified all patients presenting to the ED with a primary diagnosis of a mental health condition between 2005 and 2013. The index ED visit for an individual was defined as the first mental health ED visit which did not result in a subsequent inpatient admission. A wash-out period of one year was applied to the study cohort to ensure initial index ED visit identification. Study inclusion required continuous insurance enrollment for 12 months prior to the defined index ED visit and 31 days after the visit. Logistic regression models were used to assess independent associations of patient characteristics with return ED visits or inpatient admissions within 3, 7, and 30 days. Risk factors included sex, medical comorbidities, age, ED and inpatient utilization in the year prior to the index ED visit, calendar year and the type of mental health condition identified during the index visit. Subsequently, a time to event analysis was conducted to test the robustness of the associations. Results: A total of 366,305 ED visits due to mental health condition were identified during 2005-2013, among which 14.6% (n¼53,435) returned to the ED or had an inpatient admission within 30 days due to mental health. Among those, 43.2% (n¼23,062) of return visits were due to mental health conditions, 10.1% (n¼5,415) were due to trauma, 2.5% (n¼1,319) were due to poisoning, and 45.1% (n¼24,150) were due to other reasons. Mean time to the next utilization (ED or inpatient) was 11.7 days (median 9, standard deviation 8.6). Male sex (Odds ratio [OR], 1.08; 95% Confidence interval (CI), [1.06-1.10]), increased chronic comorbidities (test for trend, P < .0001), prior ED and inpatient utilization (test for trend, P < .0001; 4 visits vs 0 OR¼5.26 [4.55-6.25]), a history of mood disorders (OR¼1.32; 95%CI, [1.181.49]), and increasing age (test for trend, P < .0001) (Figure) were associated with increased likelihood of ED return visit or inpatient admissions within 30 days. These findings remained significant with a subsequent time to event analysis. Conclusion: In this analysis of nearly 370,000 ED visits for mental health conditions over 10 years, about 15% of patients returned to the hospital within 30 days. This analysis identifies a number of factors strongly associated with return acute care visits, which will enable clinicians to make more targeted interventions during initial evaluation.
Volume 66, no. 4s : October 2015
395
Predictors of Successful Age 12-Month Follow-Up in a Multicenter Study of Infants With Severe Bronchiolitis
Wu V, Abo-Sido N, Espinola JA, Tierney CN, Sullivan AF, Camargo CA, Jr./ Massachusetts General Hospital, Boston, MA
Study Objectives: Obtaining participant follow-up is critical to the success of prospective cohort studies. Identifying characteristics associated with successful followup can help inform efforts to retain participants in the study. We examined the characteristics that predict successful telephone follow-up with parents of acutely ill children at age 12 months. Methods: We analyzed data from a 17-center, prospective cohort study of infants (age <1 year) hospitalized with bronchiolitis. Infants were enrolled during three consecutive winter seasons (November to April) in 2011 to 2014. Site investigators collected baseline interview and medical record data during the index hospitalization. We called parents at 6-month intervals (based on the child’s age) after discharge to assess the child’s respiratory problems, subsequent emergency department visits or hospitalizations, and other factors related to recurrent wheeze development. Respondents were coded as unreachable after 28 days of unsuccessful efforts to reach the parent. All children whose parents we attempted to contact for the age 12-month follow-up interview were included in the present analysis. To identify predictors of age 12-month follow-up completion, we used chi-square, Fisher’s exact test, and multivariable logistic regression clustered by site. Two-tailed P < .05 was considered statistically significant. Results: Among 918 children, median age at enrollment was 3 months (interquartile range 2-6). Of these, 798 (87%) completed the age 12-month interview. In unadjusted analyses, age 12-month follow-up completion was more likely if the child was female, had private health insurance, an annual household income $60,000, and from the Northeast, Midwest, or West regions (all P < .05). Follow-up was less likely among non-Hispanic black children, and Hispanics (all P < .05). In adjusted analyses, follow-up completion remained more likely among parents of female children (odds ratio [OR] 1.52; 95% confidence interval [CI] 1.04-2.23; P ¼ .03), those with an annual household income $60,000 (OR 1.63; 95% CI 1.01-2.64; P ¼ .045) and, compared to the South, those in the Northeast (OR 1.91; 95% CI 1.223.01; P ¼ .005), Midwest (OR 1.97; 95% CI 1.23-3.14; P ¼ .005) and West (OR 1.64; 95% CI 1.01-2.66; P ¼ .046). Additionally, compared to non-Hispanic white children, non-Hispanic blacks (OR 0.53; 95% CI 0.35-0.82; P ¼ .004) and Hispanics (OR 0.63; 95% CI 0.43-0.91; P ¼ .014) were less likely to complete the age 12-month follow-up interview. Conclusion: Female sex, white race, greater annual household income, and residing in the Northeast, Midwest, or West predicted successful age 12-month follow-up. These findings suggest potential benefits from developing and implementing better follow-up methods, particularly for families of participants who are male, minorities, or from the South.
396
Predicting Flow in the Pediatric Emergency Department: Are Holidays Lighter?
Agoritsas K, Krinsky-Deiner M, Chao J, Sinert R/SUNY Downstate Medical Center, Brooklyn, NY
Study Objectives: One of the major aspects of emergency department (ED) operations is matching patient demand with staffing and resources to ensure
Volume 66, no. 4s : October 2015
efficient throughput. It is common belief among providers that there are fewer visits on holidays in an ED. The objective was to determine the effect of national holidays on patient volume in an urban pediatric emergency department (PED). Methods: Login dates and times were obtained for all patient visits to an urban PED between July 1, 2006 and June 30, 2013. Visits were coded for the day of the week, tour, season, and whether they occurred on a holiday or non-holiday. Comparisons between the median number of visits on holidays vs. non-holidays by season, days of the week and tours were performed. Additional comparisons of the five Monday holidays (Martin Luther King Day, Washington’s Birthday, Memorial Day, Labor Day, and Columbus Day), as well as New Year’s, Thanksgiving, and Christmas Days to non-holidays were also performed. Group comparisons were performed via Mann-Whitney U tests and Kruskal-Wallis tests (alpha¼ 0.05, 2 tails). Results: There were 101 holiday and 2,456 non-holiday days, for a total of 2,557 days between July 1, 2006 and June 30, 2013. There were 223,677 total visits, with an average yearly census of 31,954. Volume peaked on Mondays versus the other days of the week (99 vs 76-91). The summer season demonstrated the fewest visits per day relative to the other seasons (74 vs 89-91; P < .001). Compared to non-holiday Thursdays within the fall season, there were fewer visits on Thanksgiving (81 vs 92; P < .001). Compared to nonholidays within the winter season there were fewer visits on Christmas (72 vs 90; P ¼ .031). There was no significant difference between numbers of visits on Monday holidays with same day of week non-holidays within their seasons. Tour 1 (12am-8am) demonstrated more patients on holidays compared to nonholidays during the winter (16 vs 12; P < .001), spring (21 vs 12; P < .001), and summer (18 vs 11; P < .001). Tour 2 (8am-4pm) did not demonstrate any significant difference in number of visits for any of the seasons. Tour 3 (4pm12am) demonstrated fewer patients on holidays vs. non-holidays during the fall (33 vs 38; P ¼ .027), winter (34 vs 38; P ¼ .001), and summer (31 vs 34; P ¼ .017). Conclusion: There are fewer patient visits on Thanksgiving and Christmas, as well as during late afternoon/evening on several other holidays. Our findings suggest potential for adjustments in staffing and resource planning for a PED.
397
Pediatric Triage Decisionmaking in a Large-Scale Pediatric Disaster
DeGeorge L, Glick R, Ackerman A, Wu Y/Virginia Tech Carilion School of Medicine, Roanoke, VA; Carilion Clinic, Roanoke, VA
Background: Children are profoundly vulnerable during a disaster or mass casualty event and yet are an often neglected group in emergency planning. Although triage is a critical task to be completed whenever there is a surge of patients, research on current triage algorithms have not included which group of providers is best able to perform the task of patient triage. Study Objective: The primary goal of this study is to determine if health care professionals not board certified in pediatric care make the same triage decisions in a mass casualty event with a high level of confidence compared to providers trained in the field of pediatrics. A secondary goal is to analyze key patient characteristics and clinical factors that are used by providers in assigning pediatric triage classifications. Methods: This is a survey-based study conducted at Carilion Roanoke Memorial Hospital (CRMH) using 11 case scenarios. Subjects were recruited from the departments of pediatrics and emergency medicine and asked to read each case and assign a triage classification based on the JumpSTART triage algorithm with each color designation assigned a numerical value- green¼ 1, yellow¼2, red¼3, and black¼4. They were also asked to rate their level of confidence using a Likert Scale ranging from 1 to 5 with 1 being not at all confident and 5 representing very confident. Finally, they were asked to answer whether the patient needed to be seen at a children’s hospital and to state in 1-2 sentences the key elements in the case on which they based their answers to each question. An extended version of Kappa coefficient was used to compare inter-rater agreement. Mean values for reported confidence scores were determined. Categorization and qualitative analysis of clinical factors cited was also undertaken. Results: Determination of Kappa coefficient revealed fair agreement amongst raters from the pediatric department (kappa¼ 0.38), moderate agreement within the emergency medicine department (kappa¼ 0.44), and moderate agreement across all raters (kappa¼ 0.42). Both departments reported high confidence in their triage decisions with mean confidence scores of 4.37 (pediatric department) and
Annals of Emergency Medicine S143
Research Forum Abstracts 4.54 (EM department). Clinical factors cited in decision making fell into 1 of 4 categories: vital signs (cited 75 times), physical exam findings (170), mechanism of injury/history of present illness (126), or anticipation of the patient’s future needs (58). Conclusions: Fair to moderate agreement across raters suggests the need for increased training of providers on the use of the JumpSTART triage algorithm. This is supported by analysis of key clinical factors used in decisionmaking which suggest the algorithm was not consistently and appropriately applied by providers. Lack of agreement also indicates deficiencies in the triage system itself. High confidence levels from both groups aid in emergency planning by indicating either group of providers is capable of the task of triage in a large scale disaster. Additional work surveying providers under conditions that more intentionally simulate a mass casualty event and including providers from other departments can further this research.
398
Application of the National Emergency XRadiography Utilization Study Criteria and the Canadian C-spine Rule Among Children Aged 8 to 17 Years in the Emergency Department: A Retrospective Review
Pepin LC, Bressler S, Brenner C, Avarello JT, Johnson AA, Prince JM, Bank MA, Dlugacz Y, Silverman RA/Hofstra North Shore-LIJ School of Medicine, Hempstead, NY; North Shore-LIJ Health System, New Hyde Park, NY; Krasnoff Institute of Quality Management, New Hyde Park, NY
Study Objectives: Clinical rules have been developed to identify acute trauma patients who require imaging of the cervical spine. While the computed tomography (CT) scan is highly sensitive for detecting cervical spine injury (CSI), unnecessary ionizing radiation is of concern, especially in children. The clinical rules have been more extensively tested in adults; however, there is support in the literature for National Emergency X-Radiography Utilization Study criteria (NEXUS) to reliably detect injury in children over 7 years old. The Canadian Cspine Rule (CCR) has also been considered but unlike the NEXUS, validation testing has not been performed in this pediatric age group. Our goal is to determine the number of cervical CT scans that could have potentially been avoided had NEXUS and CCR been applied to children aged 8 to 17 years with acute trauma. Methods: We conducted a retrospective chart review of children aged 8 to 17 years who received a cervical CT scan for blunt trauma in the emergency departments (ED) of an adult and pediatric level I trauma center from January 2010 to November 2013. Clinical variables deemed equivalent to NEXUS and CCR were established prior to chart review. Reviewers were blinded from CT results, and the need for CT scan based on risk of CSI was determined using NEXUS and CCR criteria. Based on chart review, the CT scan was classified as indicated or not indicated. If clinical data was missing, then the rule could not be applied and this was noted. Data abstraction reproducibility of the recorded findings were confirmed through independent review of an enriched sample including all patients with abnormal CT findings and 50 randomly selected charts. Results: Four hundred thirty-two patients aged 8 to 17 years received a cervical CT scan for acute trauma with an average age of 14 years and 270 (63%) males. A total of 2.5% (11/432) had abnormal cervical CT scan findings reported, and 1% (4/ 432) of the children had clinically significant CSI requiring intervention. The injuries requiring intervention included C4, C5 compression fracture; C5, C6 avulsion fracture; C1/C2 rotary subluxation; and C7 fracture. NEXUS indicated imaging in 70% (303), did not indicate imaging in 24% (102), and could not be applied in 6% (27). CCR indicated imaging in 58% (250), did not indicate imaging in 16% (68), and could not be applied in 26% (114) due to missing range of motion documentation (ROM). 89 of the 114 children with missing ROM were discharged directly from the ED. Had normal ROM been documented in these patients, those not indicated for imaging by CCR would have risen to 36%. None of the patients with clinically significant CSI were categorized as “not indicated” for imaging with either the NEXUS or CCR tools. Conclusion: Application of the NEXUS and CCR would have reduced cervical spine CT imaging in older children aged 8 to17 years. While no serious injury was missed with either tool, a limitation of our study is the low number of serious spinal injuries. A limitation of the current medical literature includes the use of retrospective chart reviews rather than prospective validation of the rules. Given the importance of
S144 Annals of Emergency Medicine
avoiding unnecessary CT imaging in children, more work is needed to determine the sensitivity of these tools in this older pediatric age group.
399 400
Withdrawn
Emergency Department Visits for Mental Illness: Evaluation of Patterns and Risk Factors of Return Visits from Claim Database: 2005-2013
Lee S, Johnson R, Sangaralingham L, Herrin J, Campbell RL/Mayo Clinic Health System, Mankato, MN; Mayo Clinic, Rochester, MN; Yale University, New Haven, CT
Study Objectives: Mental health-related visits account for up to 12 percent of all emergency department (ED) visits in the United States. EDs are frequently used for the initial evaluation of mental health emergencies and return visits to the hospital may represent avoidable health care utilization. The primary objective was to determine risk factors associated with return ED visits or inpatient admissions following an initial mental health-related ED visit. Methods: A retrospective study was performed using Optum Labs Data Warehouse, a large nationally representative database containing administrative claims data on privately insured and Medicare Advantage enrollees. We identified all patients presenting to the ED with a primary diagnosis of a mental health condition between 2005 and 2013. The index ED visit for an individual was defined as the first mental health ED visit which did not result in a subsequent inpatient admission. A wash-out period of one year was applied to the study cohort to ensure initial index ED visit identification. Study inclusion required continuous insurance enrollment for 12 months prior to the defined index ED visit and 31 days after the visit. Logistic regression models were used to assess independent associations of patient characteristics with return ED visits or inpatient admissions within 3, 7, and 30 days. Risk factors included sex, medical comorbidities, age, ED and inpatient utilization in the year prior to the index ED visit, calendar year and the type of mental health condition identified during the index visit. Subsequently, a time to event analysis was conducted to test the robustness of the associations. Results: A total of 366,305 ED visits due to mental health condition were identified during 2005-2013, among which 14.6% (n¼53,435) returned to the ED or had an inpatient admission within 30 days due to mental health. Among those, 43.2% (n¼23,062) of return visits were due to mental health conditions, 10.1% (n¼5,415) were due to trauma, 2.5% (n¼1,319) were due to poisoning, and 45.1% (n¼24,150) were due to other reasons. Mean time to the next utilization (ED or inpatient) was 11.7 days (median 9, standard deviation 8.6). Male sex (Odds ratio [OR], 1.08; 95% Confidence interval (CI), [1.06-1.10]), increased chronic comorbidities (test for trend, P < .0001), prior ED and inpatient utilization (test for trend, P < .0001; 4 visits vs 0 OR¼5.26 [4.55-6.25]), a history of mood disorders (OR¼1.32; 95%CI, [1.181.49]), and increasing age (test for trend, P < .0001) (Figure) were associated with increased likelihood of ED return visit or inpatient admissions within 30 days. These findings remained significant with a subsequent time to event analysis. Conclusion: In this analysis of nearly 370,000 ED visits for mental health conditions over 10 years, about 15% of patients returned to the hospital within 30 days. This analysis identifies a number of factors strongly associated with return acute care visits, which will enable clinicians to make more targeted interventions during initial evaluation.
Volume 66, no. 4s : October 2015