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Comparison of Pediatric Emergency Medicine Attending Physician to Emergency Medicine Attending Physician Chest X-Ray Utilization in Pediatric Patients With Acute Wheeze
Research Forum Abstracts
304
Comparison of Pediatric Emergency Medicine Attending Physician to Emergency Medicine Attending Physician Chest X-Ray Utilization in Pediatric Patients With Acute Wheeze
Avarello J, McIver M, Ward MF, Aziz-Bose R, Wu M, Silverman R/Cohen's Children's Center, New Hyde Park, NY; North Shore University Hospital, Manhasset, NY; Long Island Jewish Medical Center, New Hyde Park, NY
Background: Among children presenting to the emergency department with acute asthma or wheezing, except for first time wheezing, chest X-rays (CXR) are typically not recommended as part of the diagnostic workup. It is not known, however, if there are differences in CXR utilization among pediatric emergency medicine (PEM) specialists as compared to general emergency medicine (EM) practitioners. In our pediatric emergency department (ED), either PEM or EM providers supervise and manage the care of children. This provides us an opportunity to compare clinical practice among the EM specialties. Study Objectives: The goal of this study was to determine whether PEM attending physician CXR utilization differed from EM attending physicians. We also compared PEM and EM treatment and disposition decisions. Methods: Our pediatric ED has an annual volume of 40,000 visits and is within a tertiary care childrens hospital. The department is staffed primarily by fellowship trained and board certified pediatric emergency medicine providers, and residency trained and board certified emergency physicians provide staffing and pediatric care. Both pediatric and emergency medicine residents rotate through the pediatric ED and may be supervised by either PEM or EM attending physicians. In this study we retrospectively collected data on children 2-17 years of age who presented to the ED from August 2010 to December 2012 with an ED diagnosis of acute asthma exacerbation or wheezing. Data was collected on the specialty of the supervising EM attending, whether a CXR was obtained and the specific CXR findings, the use of antibiotics, and the ED diagnosis and disposition. Each CXR was interpreted by a board certified pediatric radiologist. Data was presented using descriptive statistics and analyzed with the chi-square test. Results: There were data from 265 children. One hundred seventy-two (65%) of the children were managed by PEM attending physicians and 93 (35%) by EM attendings. A total of 103 (38.9%) children had a CXR and 16/103 (15.5%) were diagnosed with definite or probable pneumonia. Antibiotics were prescribed or given in the ED to 30/265 (11.3%) of all children, and 90/265 (34%) of all children were hospitalized. There were no differences in the frequency of CXR obtained by PEM as compared to the EM attending physicians (38.4% vs. 39.8%, p¼0.822). When 51 children with first wheeze were excluded, the CXR ordering patterns did not change. Among all children there were no differences in the frequency of pneumonia (6.4% vs 5.4%, p¼0.740) or antibiotic administration (11.6% vs 10.8%, p¼0.830) among PEM and EM attendings. Children cared for by PEM attendings were more likely to be hospitalized compared to EM attendings (43.0% vs. 17.2%, p<0.001). Conclusions: There were no differences in CXR ordering patterns among PEM and EM providers who cared for children with wheezing in an academic pediatric ED. Further, the findings of CXR diagnosed pneumonia were similar. An unexpected finding, however, were the much higher admission rates among children cared for by PEM attendings. Further work is needed to determine if children cared for by PEM or EM attendings have differing levels of illness acuity or whether disposition practices substantially differ among PEM and EM providers.
305
Pediatric Out-of-Hospital Electrical Cardiotherapy in the State of Michigan
Singh M, Fales W/GRMEP, Grand Rapids, MI; Western Michigan School of Medicine, Kalamazoo, MI
Study Objectives: Electrical cardiotherapy is used in the management of potentially lethal arrhythmias that may result in cardiovascular collapse and sudden cardiac arrest (SCA). Out-of-hospital therapies used by emergency medical services (EMS) include defibrillation, synchronized cardioversion, and external pacing. Therapies available to the public include automated external defibrillators (AEDs). Pediatric SCA is infrequent, affecting approximately 16,000 out-of-hospital children per year. While the majority of adult SCAs occur due to preexisting cardiac conditions, pediatric SCAs are more than twice as likely attributed to non-cardiac causes such as trauma, infection or respiratory distress. Because early detection and prevention is often futile, immediate defibrillation by EMS or by AEDs is critical in its management. We sought to determine the incidence
S110 Annals of Emergency Medicine
of pediatric out-of-hospital electrical cardiotherapy in the state of Michigan, including manual defibrillation, AEDs, cardioversion and pacing. We gathered demographic information and characteristics of the EMS response including location, response time, initial cardiac rhythm, and return of spontaneous circulation (ROSC). Methods: The Michigan EMS Information Systems (MI-EMSIS) is a database with over 4.3 million records since January 2009. EMS and First Responders are required to report any response to MI-EMSIS. MI-EMSIS was filtered by procedure codes for manual defibrillation, AEDs, synchronized cardioversion and external pacing for pediatric patients. Each case was reviewed to verify the use of electrical cardiac support. Cases were excluded if subjects were age 18, the case occurred within a hospital or scheduled inter-facility transport, or no electrical therapy was used. Results: Of the available 4,332,197 MI-EMSIS cases from 1/2009 to 3/2013, 243,403 (5.6%) cases were pediatric and 1130 (0.03%) cases were a pediatric cardiac arrest. Upon review of the cases there were only 46 confirmed defibrillations. Thirtyfive cases were manually defibrillated, 5 cases were defibrillated by an AED, and 6 cases used both manual defibrillation and AEDs. The average age was 11.5 and 63% were male. Sixty-three percent of cases occurred in a home or residence while 37% occurred in public. Eleven percent had a confirmed underlying cardiac condition, 6.5% were traumatic, and 61% had an unconfirmed etiology. Sixty-five percent were considered a primary ventricular fibrillation arrest defined by initial rhythm on a cardiac monitor or an initial shockable rhythm by an AED. EMS response time for primary arrest was 11 minutes. Seventy-four percent did not have ROSC upon arrival to a medical facility. Of the 11 AED cases, 6 were used by first responders, 4 were public access and 1 was not reported. Five AEDs were used in schools. Four cases had insufficient records and were considered “possible AED use.” Including these, the maximum possible cases from the database are 15. The MI-EMSIS database showed 3 confirmed cases of external cardiac pacing. 2 cases were of a traumatic etiology while 1 occurred after a cardiac arrest. There were 2 confirmed cases of synchronized cardioversion. Conclusions: The use of out-of-hospital pediatric electrical cardiac support is rare in the state of Michigan. Over a three-year review, only 46 cases of defibrillation by first responders were reported, with only 15 possible AED events. External pacing and synchronized cardioversion were less frequent with, only 3 and 2 cases respectively.
306
Management of Pediatric Concussion Patients by Emergency Physicians
Kinnaman KA, Mannix RC, Comstock RD, Meehan WP III/Brigham and Women’s Hospital, Boston, MA; Boston Children's Hospital, Boston, MA; Colorado School of Public Health, Aurora, CO
Study Objective: Despite an increase in concussion diagnoses among pediatric patients, little is known about the management of concussed pediatric patients in emergency departments (EDs). The objective of this study was to assess strategies used by emergency physicians when managing pediatric patients suffering from concussions. Methods: A 17-item questionnaire was emailed to members of the American Academy of Pediatrics Section on Emergency Medicine. Two serial emails were distributed at two-week intervals to non-responders. The survey included multiplechoice and free-text questions that were created by the team of investigators based on prior surveys of family practioners and physical trainers. We collected demographic information as well as specific information regarding the use of medications, neuropsychological testing, neuroimaging, return-to-play decisionmaking, and use of published guidelines. Simple descriptive statistics were used. Results: Two hundred sixty-five physicians (29%) completed the questionnaire of which 52% had been an attending for >10 years. Ninety-nine percent of respondents reported managing concussions, the majority (76%) seeing >24 concussed patients per year. Most clinicians (81%) reported using a published guideline in their management of concussions. The symptoms most likely to prompt head imaging in the ED included a focal neurological deficit (92%), altered mental status (82%), and intractable vomiting (80%). Most (91%) respondents reported using medications to manage the symptoms of concussed patients, mainly acetaminophen (78%) and non-steroidal anti-inflammatory medications (77%), although 54% used ondansetron and 7% used narcotics. More than half (56%) of respondents referred concussion patients for neuropsychological testing from the ED. Of those, nearly half (49%) refer their patients to a sports concussion clinic, while 5% refer patients to a neuropsychologist. When discussing discharge instructions, 86% of clinicians recommended follow-up with a primary care physician (PCP), 62% recommended follow-up with a sports
Volume 62, no. 4s : October 2013
304
Comparison of Pediatric Emergency Medicine Attending Physician to Emergency Medicine Attending Physician Chest X-Ray Utilization in Pediatric Patients With Acute Wheeze
Avarello J, McIver M, Ward MF, Aziz-Bose R, Wu M, Silverman R/Cohen's Children's Center, New Hyde Park, NY; North Shore University Hospital, Manhasset, NY; Long Island Jewish Medical Center, New Hyde Park, NY
Background: Among children presenting to the emergency department with acute asthma or wheezing, except for first time wheezing, chest X-rays (CXR) are typically not recommended as part of the diagnostic workup. It is not known, however, if there are differences in CXR utilization among pediatric emergency medicine (PEM) specialists as compared to general emergency medicine (EM) practitioners. In our pediatric emergency department (ED), either PEM or EM providers supervise and manage the care of children. This provides us an opportunity to compare clinical practice among the EM specialties. Study Objectives: The goal of this study was to determine whether PEM attending physician CXR utilization differed from EM attending physicians. We also compared PEM and EM treatment and disposition decisions. Methods: Our pediatric ED has an annual volume of 40,000 visits and is within a tertiary care childrens hospital. The department is staffed primarily by fellowship trained and board certified pediatric emergency medicine providers, and residency trained and board certified emergency physicians provide staffing and pediatric care. Both pediatric and emergency medicine residents rotate through the pediatric ED and may be supervised by either PEM or EM attending physicians. In this study we retrospectively collected data on children 2-17 years of age who presented to the ED from August 2010 to December 2012 with an ED diagnosis of acute asthma exacerbation or wheezing. Data was collected on the specialty of the supervising EM attending, whether a CXR was obtained and the specific CXR findings, the use of antibiotics, and the ED diagnosis and disposition. Each CXR was interpreted by a board certified pediatric radiologist. Data was presented using descriptive statistics and analyzed with the chi-square test. Results: There were data from 265 children. One hundred seventy-two (65%) of the children were managed by PEM attending physicians and 93 (35%) by EM attendings. A total of 103 (38.9%) children had a CXR and 16/103 (15.5%) were diagnosed with definite or probable pneumonia. Antibiotics were prescribed or given in the ED to 30/265 (11.3%) of all children, and 90/265 (34%) of all children were hospitalized. There were no differences in the frequency of CXR obtained by PEM as compared to the EM attending physicians (38.4% vs. 39.8%, p¼0.822). When 51 children with first wheeze were excluded, the CXR ordering patterns did not change. Among all children there were no differences in the frequency of pneumonia (6.4% vs 5.4%, p¼0.740) or antibiotic administration (11.6% vs 10.8%, p¼0.830) among PEM and EM attendings. Children cared for by PEM attendings were more likely to be hospitalized compared to EM attendings (43.0% vs. 17.2%, p<0.001). Conclusions: There were no differences in CXR ordering patterns among PEM and EM providers who cared for children with wheezing in an academic pediatric ED. Further, the findings of CXR diagnosed pneumonia were similar. An unexpected finding, however, were the much higher admission rates among children cared for by PEM attendings. Further work is needed to determine if children cared for by PEM or EM attendings have differing levels of illness acuity or whether disposition practices substantially differ among PEM and EM providers.
305
Pediatric Out-of-Hospital Electrical Cardiotherapy in the State of Michigan
Singh M, Fales W/GRMEP, Grand Rapids, MI; Western Michigan School of Medicine, Kalamazoo, MI
Study Objectives: Electrical cardiotherapy is used in the management of potentially lethal arrhythmias that may result in cardiovascular collapse and sudden cardiac arrest (SCA). Out-of-hospital therapies used by emergency medical services (EMS) include defibrillation, synchronized cardioversion, and external pacing. Therapies available to the public include automated external defibrillators (AEDs). Pediatric SCA is infrequent, affecting approximately 16,000 out-of-hospital children per year. While the majority of adult SCAs occur due to preexisting cardiac conditions, pediatric SCAs are more than twice as likely attributed to non-cardiac causes such as trauma, infection or respiratory distress. Because early detection and prevention is often futile, immediate defibrillation by EMS or by AEDs is critical in its management. We sought to determine the incidence
S110 Annals of Emergency Medicine
of pediatric out-of-hospital electrical cardiotherapy in the state of Michigan, including manual defibrillation, AEDs, cardioversion and pacing. We gathered demographic information and characteristics of the EMS response including location, response time, initial cardiac rhythm, and return of spontaneous circulation (ROSC). Methods: The Michigan EMS Information Systems (MI-EMSIS) is a database with over 4.3 million records since January 2009. EMS and First Responders are required to report any response to MI-EMSIS. MI-EMSIS was filtered by procedure codes for manual defibrillation, AEDs, synchronized cardioversion and external pacing for pediatric patients. Each case was reviewed to verify the use of electrical cardiac support. Cases were excluded if subjects were age 18, the case occurred within a hospital or scheduled inter-facility transport, or no electrical therapy was used. Results: Of the available 4,332,197 MI-EMSIS cases from 1/2009 to 3/2013, 243,403 (5.6%) cases were pediatric and 1130 (0.03%) cases were a pediatric cardiac arrest. Upon review of the cases there were only 46 confirmed defibrillations. Thirtyfive cases were manually defibrillated, 5 cases were defibrillated by an AED, and 6 cases used both manual defibrillation and AEDs. The average age was 11.5 and 63% were male. Sixty-three percent of cases occurred in a home or residence while 37% occurred in public. Eleven percent had a confirmed underlying cardiac condition, 6.5% were traumatic, and 61% had an unconfirmed etiology. Sixty-five percent were considered a primary ventricular fibrillation arrest defined by initial rhythm on a cardiac monitor or an initial shockable rhythm by an AED. EMS response time for primary arrest was 11 minutes. Seventy-four percent did not have ROSC upon arrival to a medical facility. Of the 11 AED cases, 6 were used by first responders, 4 were public access and 1 was not reported. Five AEDs were used in schools. Four cases had insufficient records and were considered “possible AED use.” Including these, the maximum possible cases from the database are 15. The MI-EMSIS database showed 3 confirmed cases of external cardiac pacing. 2 cases were of a traumatic etiology while 1 occurred after a cardiac arrest. There were 2 confirmed cases of synchronized cardioversion. Conclusions: The use of out-of-hospital pediatric electrical cardiac support is rare in the state of Michigan. Over a three-year review, only 46 cases of defibrillation by first responders were reported, with only 15 possible AED events. External pacing and synchronized cardioversion were less frequent with, only 3 and 2 cases respectively.
306
Management of Pediatric Concussion Patients by Emergency Physicians
Kinnaman KA, Mannix RC, Comstock RD, Meehan WP III/Brigham and Women’s Hospital, Boston, MA; Boston Children's Hospital, Boston, MA; Colorado School of Public Health, Aurora, CO
Study Objective: Despite an increase in concussion diagnoses among pediatric patients, little is known about the management of concussed pediatric patients in emergency departments (EDs). The objective of this study was to assess strategies used by emergency physicians when managing pediatric patients suffering from concussions. Methods: A 17-item questionnaire was emailed to members of the American Academy of Pediatrics Section on Emergency Medicine. Two serial emails were distributed at two-week intervals to non-responders. The survey included multiplechoice and free-text questions that were created by the team of investigators based on prior surveys of family practioners and physical trainers. We collected demographic information as well as specific information regarding the use of medications, neuropsychological testing, neuroimaging, return-to-play decisionmaking, and use of published guidelines. Simple descriptive statistics were used. Results: Two hundred sixty-five physicians (29%) completed the questionnaire of which 52% had been an attending for >10 years. Ninety-nine percent of respondents reported managing concussions, the majority (76%) seeing >24 concussed patients per year. Most clinicians (81%) reported using a published guideline in their management of concussions. The symptoms most likely to prompt head imaging in the ED included a focal neurological deficit (92%), altered mental status (82%), and intractable vomiting (80%). Most (91%) respondents reported using medications to manage the symptoms of concussed patients, mainly acetaminophen (78%) and non-steroidal anti-inflammatory medications (77%), although 54% used ondansetron and 7% used narcotics. More than half (56%) of respondents referred concussion patients for neuropsychological testing from the ED. Of those, nearly half (49%) refer their patients to a sports concussion clinic, while 5% refer patients to a neuropsychologist. When discussing discharge instructions, 86% of clinicians recommended follow-up with a primary care physician (PCP), 62% recommended follow-up with a sports
Volume 62, no. 4s : October 2013