- Email: [email protected]
Tertiary Care Referrals for Fractures in Children
ORIGINAL ARTICLE
Tertiary Care Referrals for Fractures in Children Jennifer K. Marsh, CPNP, David J. Murray, MD, Anshuman Sharma, MD, Kavya Narayana Reddy, MD, Alyssa Naes Purpose: With limited local access to pediatric subspecialty care outside
major metropolitan areas, tertiary care hospitals treat many children originally seen at outside facilities for relatively brief but urgent surgical procedures. This referral-based care imposes significant financial and psychological stress on the families. Design: Prospective, survey methodology was used. Methods: Families of children aged 0-18 years admitted to the St. Louis Children’s Hospital for surgical repair of fractures were surveyed. The questionnaire was developed by the research team and measured a variety of fields. Findings: The operative procedure in the majority of these children was relatively brief in both groups, often less than one hour. The time of injury to their discharge from our hospital, however, extended to 36 hours. Families missed several days of work. Many children were kept NPO longer than needed. Conclusions: Our preliminary evaluation suggests that a relatively minor unexpected surgery of a child can impose significant financial, organizational, and psychological burden on the family. Keywords: pediatrics, tertiary care referrals, orthopaedics. Ó 2017 by American Society of PeriAnesthesia Nurses
THERE ARE A VARIETY of injuries in children that require the expertise of a pediatric orthopaedic surgeon and referral to a pediatric hospital for definitive surgical management. For many children who sustain fractures, the time from their initial injury until Jennifer K. Marsh, CPNP, Washington University in Saint Louis, St. Louis Children’s Hospital, St. Louis, MO; David J. Murray, MD, Washington University in Saint Louis, St. Louis Children’s Hospital, St. Louis, MO; Anshuman Sharma, MD, Washington University in Saint Louis, St. Louis Children’s Hospital, St. Louis, MO; Kavya Narayana Reddy, MD, Rutgers New Jersey Medical School, Rutgers University, Newark, NJ; and Alyssa Naes, Truman State University, Kirksville, MO. Conflict of interest: None to report. Address correspondence to Jennifer K. Marsh, Washington University in Saint Louis, St. Louis Children’s Hospital 5S 31, One Children’s Place, St. Louis, MO 63110; e-mail address: [email protected]. Ó 2017 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2016.12.008
Journal of PeriAnesthesia Nursing, Vol -, No - (-), 2017: pp 1-5
their definitive surgical repair is often delayed because of the need for transfer from their local emergency room (ER). Supracondylar fractures are a common pediatric elbow injury that are historically associated with increased morbidity because of the type of fracture, neurovascular complications, and compartment syndrome, all important reasons to consider repair at a pediatric hospital.1,2 In conducting preoperative assessments of these children, our impression was that many of the children and families had experienced a relatively prolonged interval between injury and their surgical treatment. Although a variety of studies are available that describe the impact on children and their families of more critical pediatric illnesses and injuries, relatively few studies are available that describe the impact of injuries that require brief operations.3,4 In many urban settings, these are frequently accomplished in an outpatient setting without the need for admission to the hospital.
1
MARSH ET AL
2
The purpose of this study was to assess the care of children who sustained an extremity fracture and compare those children who required transfer from an outside hospital to children who arrived directly at our ER. Our goal was to determine whether transfer from an outside hospital altered the delivery of care and lengthened the duration of hospitalization. Our longer-term goal was to better understand the impact and to potentially develop strategies that might be implemented to improve the care and hospital experience of children and their families.
Methods and Design To assess the impact of the injury, we developed a parental survey. Questionnaires are widely used data collection methods. The purpose of the questionnaire was to compare the impact on the child and family of those who were transferred from an outside hospital to those children and families who arrived directly to our ER. The questions used in the survey were divided into questions about the management of the child before their arrival at our hospital and questions about the impact of the hospitalization on the family including work, other children and their ability to be with their hospitalized child. The questionnaire was trialed at our institution; both the validity and reliability of the questionnaire were assessed. The validity of the questions was assessed by asking parents whether there were important questions that were missing on the questionnaire. The reliability of the questionnaire was assessed by determining if the families’ answers to the written questions were similar to their answers in an interview setting. The 38-items on the survey included demographic information about the family, questions about the child’s care from the time of injury until their arrival at our hospital, and a third set of questions about the care after their arrival at our tertiary care hospital. The goal of the questionnaire was to determine the time between the child’s injury and arrival at our hospital, but also to evaluate patient care after arrival at the hospital, as well as to determine some additional family factors associated with the injury including the amount of time missed from work, the support available to the families, impact on siblings, as well as some of the details of the child’s care from arrival to discharge.
After obtaining approval from our institutional review board and informed written parental consent, the families of 51 children admitted with fractures participated in the study. The parents were approached for consent after their admission to the hospital when the operation was scheduled. In addition to the survey, we also reviewed the child’s hospital record to determine information related to their stay. The chart review included a variety of times recorded at our hospital including the time of arrival in the ER, time of admission to the hospital, time to operation, duration of operation, as well as time to discharge after operation. The chart review included the child’s pain management, the duration of fasting, and any perioperative complications.
Findings Fifty-one parents of patients aged 0 to 18 years agreed to participate in the study and responded to the survey. The children had a variety of injuries in different age groups. The most common injury requiring transfer was a supracondylar fracture (Table 1). Fifty-seven percent of the children (n 5 29) came by private car with the remaining 43% (n 5 22) arriving by ambulance. The children who were initially evaluated at an outside hospital were for the most part from a greater distance from our hospital; the majority of these families took at least 4 hours to reach the St. Louis Children’s Hospital (Figure 1).
Table 1. Fracture Types
Age, y Mean Standard deviation Type of injury Supracondylar, humerus/olecranon, elbow Radial/ulnar, forearm, arm Femur, tibia/fibula, ankle Clavicular Finger
Outside Hospital
Pediatric Hospital
9.567 4.25
9 4.74
16
11
4 10 1 0
4 6 0 1
TERTIARY CARE REFERRALS FOR FRACTURES
3
Number of Patients
20 OSH 15
PH
15
14
10
12
5
0
2 1
4-6
7-9
0 0
0 1
0 1
1 4
10-12
12-24
>24
No Answer
0 1-3
Time (Hours)
Figure 1. Number of hours to reach the pediatric ER for OSH transfer and PH direct. ER, emergency room; OSH, outside hospital; PH, pediatric hospital. This figure is available in color online at www.jopan.org.
The operative procedure in most of these children was relatively brief in both groups, often less than 1 hour; however, from the time of injury to their discharge from our hospital extended to 36 hours. Most of their stay was in the preoperative period. The combination of the time required to arrive at the hospital as well as the duration of hospital stay until the operating room (OR) constituted the major portion of their time of admission (Figure 2).
(Figure 3). Children were left NPO greater than current pediatric anesthesia recommendations; in fact, only one child met this recommendation. Most patients were NPO far longer than recommended, four patients (8%) were NPO greater than 24 hours and 33% (n 5 17) of patients were NPO for 12 to 24 hours (Figure 3).
Families often miss several days of work, 34 of 51, 66% people surveyed missed between 1 and 3 days of work. Twenty-two of the 51 families, 43%, missed work without any pay. Patients are often transferred from outside hospitals from distances greater than an hour away, 43% lived over an hour away (Table 2).
To our knowledge, few studies have examined the impact of a relatively brief emergency operative procedure and hospitalization on a family. We would like to better understand the effect an emergency surgery has on a family, including the potential financial burden. In addition, we would like to look at the experiences and expectations of families whose child is undergoing an unplanned surgical procedure.
An additional finding was that many of these children were kept NPO (nothing by mouth) for prolonged periods, with 26 of 51 patients, 51%, NPO for greater than 10 hours before surgery
Conclusions
There is some literature that looks at the effect a Pediatric Intensive Care Unit stay has on a family;
45
Time (Hours)
40 35 30 25 20
OSH
15
PH
10 5 0 Time of Injury to Pediatric ER
OR Times
Time of Injury to Discharge
Figure 2. Injury to arrival, OR times, and injury to discharge. ER, emergency room; OR, operation room; OSH, outside hospital; PH, pediatric hospital. This figure is available in color online at www.jopan.org.
MARSH ET AL
4
Table 2. Days of Work Missed Days Missed of Work, d 0 1 to 3 4 to 6 7 to 9 .9 No answer
Outside Hospital
Pediatric Hospital
2 24 3 1 1 0
6 10 2 0 0 2
however, none is specific to an unplanned surgical procedure. In addition, there are several studies that look at the effect an ER trip has on a family, but again none to an unplanned surgical procedure, most always requiring overnight hospitalization, even if brief.5 It is identified that most parents are fairly inaccurate regarding their expectations of care. Parental perceptions are commonly associated with satisfaction.6,7
situation for a parent.8 Despite the availability of subspecialty care and relatively brief operation, most families were transferred from outside facilities. We also identified opportunities for improvement in our hospital care in reducing wait times, reducing the days of missed work, and thus reducing the disruption associated with these injuries. The inferred cost secondary to missed days of work, cost of travel, and associated expenses with gas, lodging, and food are also of concern. Attempting to educate these families on arrival regarding many of these factors will guide their expectations and improve outcomes.9 Parents from out of town are more likely to incur greater costs.10
Nurse practitioners often facilitate care for these patients and it is paramount they understand the potential psychological, financial, and social burden these minor injuries have on families. We chose this population secondary to the need for expertise of a tertiary care site secondary to its relatively high morbidity.
We feel that the psychosocial, financial, and anticipated expectations of the families are underappreciated. It has been noted that children who feel more prepared and have a better understanding of their hospitalization have decreased stress and trauma.11 Ensuring child life services are involved would help to facilitate this. In addition, there may be specific indicators of parental dissatisfaction that can be used in targeted quality improvement initiatives directed at the preoperative phase in an effort to better understand family perspective of the unplanned surgical intervention on a child.12,13
Our preliminary evaluation suggests that a relatively minor unexpected surgery of a child can impose significant financial, organizational, and psychological burden on the family. Previous studies have concluded a hospitalization of a child is a stressful
We would like to attempt to examine wait times in the emergency unit, improving expedition of OR times. Facilitate a better communication process between the OR and surgical services, as well as anesthesia to minimize NPO times. Most often
18
Number of Patients
16
17
14
15
12 10 8
9
6 4
5 4
2
1
0 1-3
4-6
7-9
10 - 12
12 - 24
> 24
No Answer
Number of Hours Figure 3. NPO times. NPO, nothing by mouth. This figure is available in color online at www.jopan.org.
TERTIARY CARE REFERRALS FOR FRACTURES
5
parents have improved satisfaction with a perceived quality of communication.14,15 Wait times, whether it is for surgical times or NPO status can cause families undo stress and decrease patient satisfaction.12 It is hard to gage even appropriate NPO times and instructions from these families.6 Many of these children were kept NPO for prolonged periods, 26 of 51 patients, 51% were NPO for greater than 10 hours
before surgery (Figure 3). Children were left NPO greater than current pediatric anesthesia recommendations; in fact, only one child met this recommendation.
Supplementary data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.jopan.2016. 12.008.
References 1. Slobogean BL, Jackman H, Tennant S, Slobogean GP, Mulpuri K. Iatrogenic ulnar nerve injury after the surgical treatment of displaced supracondylar fractures of the humerus: number needed to harm, a systematic review. J Pediatr Orthop. 2010;30:430-436. 2. Brauer CA, Lee BM, Bae DS, Waters PM, Kocher MS. A systematic review of medial and lateral entry pinning versus lateral entry pinning for supracondylar fractures of the humerus. J Pediatr Orthop. 2007;27:181-186. 3. Jee RA, Shepherd JR, Boyles CE, Marsh MJ, Thomas PW, Ross OC. Evaluation and comparison of parental needs, stressors, and coping strategies in a pediatric intensive care unit. Pediatr Crit Care Med. 2012;13:e166-e172. 4. Ramsdell KD, Morrison M, Kassam-Adams N, Marsac ML. A qualitative analysis of children’s emotional reactions during hospitalization following injury. J Trauma Nurs. 2016;23: 194-201. 5. Waseem M, Ravi L, Rodeos M, Ganti S. Parental perception of waiting time and its influence on parental satisfaction in an urban pediatric emergency department: Are parents accurate in determining waiting time? South Med Assoc. 2003;96: 880-883. 6. Harris N, Hostetler MA. Parental expectations of care and charges in a tertiary care pediatric ED. Am J Emerg Med. 2002; 20:601-603. 7. Thompson AD, Yarnold RP. Relating patient satisfaction to waiting time perceptions and expectations: the disconfirmation paradigm. Acad Emerg Med. 2008;2:12.
8. Commodari E. Children staying in the hospital: a research on psychological stress of caregivers. Ital J Pediatr. 2010;36:40. 9. Soremekun OA, Takayesu JK, Bohan SJ. Framework for analyzing wait times and other factors that impact patient satisfaction in the emergency department. J Emerg Med. 2011;41: 686-692. 10. Stanwick RS, Horne JM, Peabody DM, Postuma R. Daycare versus inpatient pediatric surgery: a comparison of cost incurred by parents. CMAJ. 1987;137:21-26. 11. Jensen CS, Jackson K, Kolbaek R, Glasdam S. Children’s experiences of acute hospitalization to a paediatric emergency and assessment unit - A qualitative study. J Child Health Care. 2012;16:263-273. 12. Thompson DA, Yarnold PR, Williams DR, Adams SL. Effects of actual waiting time, perceived waiting time, information delivery, and expressive quality on patient satisfaction in the emergency department. Ann Emerg Med. 1996;28:657-665. 13. Sun BC, Adams J, Orav JE, Rucker DW, Brennan TA, Burstin HR. Determinants of patient satisfaction and willingness to return with emergency care. Ann Emerg Med. 2000;35: 426-434. 14. Byczkowski TL. A comprehensive view of parental satisfaction with pediatric emergency department visits. Ann Emerg Med. 2013;62:340-350. 15. Toma G, Triner W, McNutt LA. Patient satisfaction as a function of emergency department previsit expectations. Ann Emerg Med. 2009;54:360-367.e6.
Tertiary Care Referrals for Fractures in Children Jennifer K. Marsh, CPNP, David J. Murray, MD, Anshuman Sharma, MD, Kavya Narayana Reddy, MD, Alyssa Naes Purpose: With limited local access to pediatric subspecialty care outside
major metropolitan areas, tertiary care hospitals treat many children originally seen at outside facilities for relatively brief but urgent surgical procedures. This referral-based care imposes significant financial and psychological stress on the families. Design: Prospective, survey methodology was used. Methods: Families of children aged 0-18 years admitted to the St. Louis Children’s Hospital for surgical repair of fractures were surveyed. The questionnaire was developed by the research team and measured a variety of fields. Findings: The operative procedure in the majority of these children was relatively brief in both groups, often less than one hour. The time of injury to their discharge from our hospital, however, extended to 36 hours. Families missed several days of work. Many children were kept NPO longer than needed. Conclusions: Our preliminary evaluation suggests that a relatively minor unexpected surgery of a child can impose significant financial, organizational, and psychological burden on the family. Keywords: pediatrics, tertiary care referrals, orthopaedics. Ó 2017 by American Society of PeriAnesthesia Nurses
THERE ARE A VARIETY of injuries in children that require the expertise of a pediatric orthopaedic surgeon and referral to a pediatric hospital for definitive surgical management. For many children who sustain fractures, the time from their initial injury until Jennifer K. Marsh, CPNP, Washington University in Saint Louis, St. Louis Children’s Hospital, St. Louis, MO; David J. Murray, MD, Washington University in Saint Louis, St. Louis Children’s Hospital, St. Louis, MO; Anshuman Sharma, MD, Washington University in Saint Louis, St. Louis Children’s Hospital, St. Louis, MO; Kavya Narayana Reddy, MD, Rutgers New Jersey Medical School, Rutgers University, Newark, NJ; and Alyssa Naes, Truman State University, Kirksville, MO. Conflict of interest: None to report. Address correspondence to Jennifer K. Marsh, Washington University in Saint Louis, St. Louis Children’s Hospital 5S 31, One Children’s Place, St. Louis, MO 63110; e-mail address: [email protected]. Ó 2017 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2016.12.008
Journal of PeriAnesthesia Nursing, Vol -, No - (-), 2017: pp 1-5
their definitive surgical repair is often delayed because of the need for transfer from their local emergency room (ER). Supracondylar fractures are a common pediatric elbow injury that are historically associated with increased morbidity because of the type of fracture, neurovascular complications, and compartment syndrome, all important reasons to consider repair at a pediatric hospital.1,2 In conducting preoperative assessments of these children, our impression was that many of the children and families had experienced a relatively prolonged interval between injury and their surgical treatment. Although a variety of studies are available that describe the impact on children and their families of more critical pediatric illnesses and injuries, relatively few studies are available that describe the impact of injuries that require brief operations.3,4 In many urban settings, these are frequently accomplished in an outpatient setting without the need for admission to the hospital.
1
MARSH ET AL
2
The purpose of this study was to assess the care of children who sustained an extremity fracture and compare those children who required transfer from an outside hospital to children who arrived directly at our ER. Our goal was to determine whether transfer from an outside hospital altered the delivery of care and lengthened the duration of hospitalization. Our longer-term goal was to better understand the impact and to potentially develop strategies that might be implemented to improve the care and hospital experience of children and their families.
Methods and Design To assess the impact of the injury, we developed a parental survey. Questionnaires are widely used data collection methods. The purpose of the questionnaire was to compare the impact on the child and family of those who were transferred from an outside hospital to those children and families who arrived directly to our ER. The questions used in the survey were divided into questions about the management of the child before their arrival at our hospital and questions about the impact of the hospitalization on the family including work, other children and their ability to be with their hospitalized child. The questionnaire was trialed at our institution; both the validity and reliability of the questionnaire were assessed. The validity of the questions was assessed by asking parents whether there were important questions that were missing on the questionnaire. The reliability of the questionnaire was assessed by determining if the families’ answers to the written questions were similar to their answers in an interview setting. The 38-items on the survey included demographic information about the family, questions about the child’s care from the time of injury until their arrival at our hospital, and a third set of questions about the care after their arrival at our tertiary care hospital. The goal of the questionnaire was to determine the time between the child’s injury and arrival at our hospital, but also to evaluate patient care after arrival at the hospital, as well as to determine some additional family factors associated with the injury including the amount of time missed from work, the support available to the families, impact on siblings, as well as some of the details of the child’s care from arrival to discharge.
After obtaining approval from our institutional review board and informed written parental consent, the families of 51 children admitted with fractures participated in the study. The parents were approached for consent after their admission to the hospital when the operation was scheduled. In addition to the survey, we also reviewed the child’s hospital record to determine information related to their stay. The chart review included a variety of times recorded at our hospital including the time of arrival in the ER, time of admission to the hospital, time to operation, duration of operation, as well as time to discharge after operation. The chart review included the child’s pain management, the duration of fasting, and any perioperative complications.
Findings Fifty-one parents of patients aged 0 to 18 years agreed to participate in the study and responded to the survey. The children had a variety of injuries in different age groups. The most common injury requiring transfer was a supracondylar fracture (Table 1). Fifty-seven percent of the children (n 5 29) came by private car with the remaining 43% (n 5 22) arriving by ambulance. The children who were initially evaluated at an outside hospital were for the most part from a greater distance from our hospital; the majority of these families took at least 4 hours to reach the St. Louis Children’s Hospital (Figure 1).
Table 1. Fracture Types
Age, y Mean Standard deviation Type of injury Supracondylar, humerus/olecranon, elbow Radial/ulnar, forearm, arm Femur, tibia/fibula, ankle Clavicular Finger
Outside Hospital
Pediatric Hospital
9.567 4.25
9 4.74
16
11
4 10 1 0
4 6 0 1
TERTIARY CARE REFERRALS FOR FRACTURES
3
Number of Patients
20 OSH 15
PH
15
14
10
12
5
0
2 1
4-6
7-9
0 0
0 1
0 1
1 4
10-12
12-24
>24
No Answer
0 1-3
Time (Hours)
Figure 1. Number of hours to reach the pediatric ER for OSH transfer and PH direct. ER, emergency room; OSH, outside hospital; PH, pediatric hospital. This figure is available in color online at www.jopan.org.
The operative procedure in most of these children was relatively brief in both groups, often less than 1 hour; however, from the time of injury to their discharge from our hospital extended to 36 hours. Most of their stay was in the preoperative period. The combination of the time required to arrive at the hospital as well as the duration of hospital stay until the operating room (OR) constituted the major portion of their time of admission (Figure 2).
(Figure 3). Children were left NPO greater than current pediatric anesthesia recommendations; in fact, only one child met this recommendation. Most patients were NPO far longer than recommended, four patients (8%) were NPO greater than 24 hours and 33% (n 5 17) of patients were NPO for 12 to 24 hours (Figure 3).
Families often miss several days of work, 34 of 51, 66% people surveyed missed between 1 and 3 days of work. Twenty-two of the 51 families, 43%, missed work without any pay. Patients are often transferred from outside hospitals from distances greater than an hour away, 43% lived over an hour away (Table 2).
To our knowledge, few studies have examined the impact of a relatively brief emergency operative procedure and hospitalization on a family. We would like to better understand the effect an emergency surgery has on a family, including the potential financial burden. In addition, we would like to look at the experiences and expectations of families whose child is undergoing an unplanned surgical procedure.
An additional finding was that many of these children were kept NPO (nothing by mouth) for prolonged periods, with 26 of 51 patients, 51%, NPO for greater than 10 hours before surgery
Conclusions
There is some literature that looks at the effect a Pediatric Intensive Care Unit stay has on a family;
45
Time (Hours)
40 35 30 25 20
OSH
15
PH
10 5 0 Time of Injury to Pediatric ER
OR Times
Time of Injury to Discharge
Figure 2. Injury to arrival, OR times, and injury to discharge. ER, emergency room; OR, operation room; OSH, outside hospital; PH, pediatric hospital. This figure is available in color online at www.jopan.org.
MARSH ET AL
4
Table 2. Days of Work Missed Days Missed of Work, d 0 1 to 3 4 to 6 7 to 9 .9 No answer
Outside Hospital
Pediatric Hospital
2 24 3 1 1 0
6 10 2 0 0 2
however, none is specific to an unplanned surgical procedure. In addition, there are several studies that look at the effect an ER trip has on a family, but again none to an unplanned surgical procedure, most always requiring overnight hospitalization, even if brief.5 It is identified that most parents are fairly inaccurate regarding their expectations of care. Parental perceptions are commonly associated with satisfaction.6,7
situation for a parent.8 Despite the availability of subspecialty care and relatively brief operation, most families were transferred from outside facilities. We also identified opportunities for improvement in our hospital care in reducing wait times, reducing the days of missed work, and thus reducing the disruption associated with these injuries. The inferred cost secondary to missed days of work, cost of travel, and associated expenses with gas, lodging, and food are also of concern. Attempting to educate these families on arrival regarding many of these factors will guide their expectations and improve outcomes.9 Parents from out of town are more likely to incur greater costs.10
Nurse practitioners often facilitate care for these patients and it is paramount they understand the potential psychological, financial, and social burden these minor injuries have on families. We chose this population secondary to the need for expertise of a tertiary care site secondary to its relatively high morbidity.
We feel that the psychosocial, financial, and anticipated expectations of the families are underappreciated. It has been noted that children who feel more prepared and have a better understanding of their hospitalization have decreased stress and trauma.11 Ensuring child life services are involved would help to facilitate this. In addition, there may be specific indicators of parental dissatisfaction that can be used in targeted quality improvement initiatives directed at the preoperative phase in an effort to better understand family perspective of the unplanned surgical intervention on a child.12,13
Our preliminary evaluation suggests that a relatively minor unexpected surgery of a child can impose significant financial, organizational, and psychological burden on the family. Previous studies have concluded a hospitalization of a child is a stressful
We would like to attempt to examine wait times in the emergency unit, improving expedition of OR times. Facilitate a better communication process between the OR and surgical services, as well as anesthesia to minimize NPO times. Most often
18
Number of Patients
16
17
14
15
12 10 8
9
6 4
5 4
2
1
0 1-3
4-6
7-9
10 - 12
12 - 24
> 24
No Answer
Number of Hours Figure 3. NPO times. NPO, nothing by mouth. This figure is available in color online at www.jopan.org.
TERTIARY CARE REFERRALS FOR FRACTURES
5
parents have improved satisfaction with a perceived quality of communication.14,15 Wait times, whether it is for surgical times or NPO status can cause families undo stress and decrease patient satisfaction.12 It is hard to gage even appropriate NPO times and instructions from these families.6 Many of these children were kept NPO for prolonged periods, 26 of 51 patients, 51% were NPO for greater than 10 hours
before surgery (Figure 3). Children were left NPO greater than current pediatric anesthesia recommendations; in fact, only one child met this recommendation.
Supplementary data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.jopan.2016. 12.008.
References 1. Slobogean BL, Jackman H, Tennant S, Slobogean GP, Mulpuri K. Iatrogenic ulnar nerve injury after the surgical treatment of displaced supracondylar fractures of the humerus: number needed to harm, a systematic review. J Pediatr Orthop. 2010;30:430-436. 2. Brauer CA, Lee BM, Bae DS, Waters PM, Kocher MS. A systematic review of medial and lateral entry pinning versus lateral entry pinning for supracondylar fractures of the humerus. J Pediatr Orthop. 2007;27:181-186. 3. Jee RA, Shepherd JR, Boyles CE, Marsh MJ, Thomas PW, Ross OC. Evaluation and comparison of parental needs, stressors, and coping strategies in a pediatric intensive care unit. Pediatr Crit Care Med. 2012;13:e166-e172. 4. Ramsdell KD, Morrison M, Kassam-Adams N, Marsac ML. A qualitative analysis of children’s emotional reactions during hospitalization following injury. J Trauma Nurs. 2016;23: 194-201. 5. Waseem M, Ravi L, Rodeos M, Ganti S. Parental perception of waiting time and its influence on parental satisfaction in an urban pediatric emergency department: Are parents accurate in determining waiting time? South Med Assoc. 2003;96: 880-883. 6. Harris N, Hostetler MA. Parental expectations of care and charges in a tertiary care pediatric ED. Am J Emerg Med. 2002; 20:601-603. 7. Thompson AD, Yarnold RP. Relating patient satisfaction to waiting time perceptions and expectations: the disconfirmation paradigm. Acad Emerg Med. 2008;2:12.
8. Commodari E. Children staying in the hospital: a research on psychological stress of caregivers. Ital J Pediatr. 2010;36:40. 9. Soremekun OA, Takayesu JK, Bohan SJ. Framework for analyzing wait times and other factors that impact patient satisfaction in the emergency department. J Emerg Med. 2011;41: 686-692. 10. Stanwick RS, Horne JM, Peabody DM, Postuma R. Daycare versus inpatient pediatric surgery: a comparison of cost incurred by parents. CMAJ. 1987;137:21-26. 11. Jensen CS, Jackson K, Kolbaek R, Glasdam S. Children’s experiences of acute hospitalization to a paediatric emergency and assessment unit - A qualitative study. J Child Health Care. 2012;16:263-273. 12. Thompson DA, Yarnold PR, Williams DR, Adams SL. Effects of actual waiting time, perceived waiting time, information delivery, and expressive quality on patient satisfaction in the emergency department. Ann Emerg Med. 1996;28:657-665. 13. Sun BC, Adams J, Orav JE, Rucker DW, Brennan TA, Burstin HR. Determinants of patient satisfaction and willingness to return with emergency care. Ann Emerg Med. 2000;35: 426-434. 14. Byczkowski TL. A comprehensive view of parental satisfaction with pediatric emergency department visits. Ann Emerg Med. 2013;62:340-350. 15. Toma G, Triner W, McNutt LA. Patient satisfaction as a function of emergency department previsit expectations. Ann Emerg Med. 2009;54:360-367.e6.