Showing posts with label ED. Show all posts
Showing posts with label ED. Show all posts

Monday, September 28, 2015

When Your Back Is Turned: ER Visits for Medication Ingestions and Unsupervised Children


By: Joann Schulte  DO, MPH; Editorial Board Member 

     Open the bottle by getting through the safety lid, dose appropriately and then have your child swallow the
pill or liquid.   It’s funny how a young child won’t do that when you or your spouse wants that to happen.   And as soon as your back is turned, it’s amazing what a child can get into and swallow.    
     But at least children are doing less unsupervised ingestions of medications   according to new research published this month in Pediatrics.  Lovegrove et al. with the Centers for Disease Control and Prevention (doi: 10.1542/peds.2015-2092) found that the estimated number of pediatric emergency room (ER) visits for unsupervised  medication exposures has declined since 2010.  The Atlanta researchers used data from the National Electronic Injury Surveillance System/Cooperative Adverse Drug Event Surveillance Project for the years 2004-2013.  Their data comes from a public health surveillance system that draws from a nationally representative sample of hospitals with at least six pediatric beds and an ER that operates 24 hours a day.  Since 2010, the number of ER visits has declined an average of 6.7% annually to an estimated total of 59,092 estimated visits in 2013.  The estimated number of visits for an unsupervised ingestion at the peak in 2010 was 75,842.
      The decline in ER visits is good news, but what the children are swallowing is still reason for concern.  Among single substance ingestions in this study, children most frequently swallowed solid prescription medications (45.9^), over the counter (OTC) solid medications (22.3%) and   liquid OTC medications (12.4%).  Nine percent of the ingestions involved more than one medication.
      Among prescription drugs, 260 different medications were swallowed by children, most frequently opioids (13.8%) and benzodiazepines (12.7%).  The OTC liquids most frequently reported were acetaminophen (32.9%), cold/cough remedies (27.5%), ibuprofen (15.7%) and diphenhydramine (15.6%).
     The CDC researchers suggested that OTC oral medications are an important topic for further prevention efforts since only four OTC medications (named in above paragraph) account for 91% of such ingestions.  Most such medications have child resistant packaging, but that packaging requires a parent or other adult to put the safety cap back on the medication and secure it after each use.   Newer products now being tested incorporate passive safety features such as flow restriction and single use packaging which can offer a secondary safety barrier.  The FDA is strongly considering the use of such packaging as a mandate on OTC liquid acetaminophen products. 
      The report showing the decline in  unsupervised pediatric ingestions is good news, but also evidence that more effort is needed to keep young children from still gaining access to medications when a supervising adult or older child is not around.

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Monday, September 29, 2014

If You See One Emergency Department Approach to Febrile Infants, You See Only One of Many Approaches

By: Lewis First, MD, MS; Editor-in-Chief 
Photo by Joseph Nicola via Flickr

Nothing provokes more discussion in a clinical conference than asking, “What is the best way to diagnose and manage febrile infants when you don’t want to miss a serious bacterial infection?” Do all infants under 3-months-old need a full sepsis evaluation, some, none over a month, or is the approach solely dependent on immunization status of the child, family or community?

While algorithms and guidelines exist as to best practice based on evidence to date, what really happens in emergency departments when these children are evaluated?

Aronson et al. (doi: 10.1542/peds.2014-1382) share with us the results of a retrospective cohort of more than 17,000 infants seen in 37 different emergency departments (EDs) to look at patient and hospital level variation in diagnostic testing, treatment and disposition. The variations across EDs and patients is stark and worth your attention. If there was ever a need for a well-circulated, evidence-based common approach to these young infants and their fevers, this study certainly calls for one.

So what do you do with your febrile babies under 3 months of age? Do you follow a care pathway or guideline? If so, which one? Share with us your thoughts on your approach to febrile infants seen in emergency departments or your office by sending us your comments to this blog, via an eLetter, or on Facebook or Twitter.

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Friday, August 15, 2014

Variation in Pediatric Emergency Department Admissions Rates

Pediatrics Editorial Board Member Joann Schulte, DO, MPH, shares her expert perspective on a new article from our September issue. To learn more about Dr. Schulte and her work in general pediatrics and preventive medicine, check out her bio on our Contributors page.

By: Joann Schulte, DO, MPH

Photo by Dana Beveridge via Flickr
To admit or not to admit is the question in the pediatric emergency room. Some children are deposited into the waiting line at the ER because there’s no primary care provider available. Others roll in with the siren blaring and an escort of paramedics. Which children go home and which stay to be admitted varies greatly according to new research published in the September issue of Pediatrics.

Four researchers at Boston Children’s Hospital led by Dr. Florence Bourgeois (doi: 10.1542/peds.2014-1278) looked at data for a 3-year period ending in 2012, examining variation in admissions to tertiary pediatric hospitals. Using data from the Pediatric Hospital Information System, an administrative database containing information about pediatric admissions and visits, the researchers focused on seven common diagnoses that could be serious, resulting in admissions approximately 10 percent of the time: asthma, cellulitis, bronchiolitis, pneumonia, kidney infections, seizures and concussions.

Wide variations in admissions were found for concussion (between 5 and72 percent), pneumonia (19 to 69 percent) and bronchiolitis (19 to 65 percent). Such differences might be related to the patient population, practice patterns of physicians and availability of care in other settings.

Understanding the variation in care is an important part of providing the best care for children. Such research is also important in understanding factors associated with admissions, which is a more expensive form of care. In 2006, the median daily cost for a pediatric admission was estimated to be $3,000.

How do the admission rates reported in this study compare to those at your hospital? Leave a comment, or join in the discussion over on our journal's website, Facebook or Twitter.

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Thursday, June 26, 2014

Acute Concussion Symptom Severity and Delayed Symptom Resolution

Pediatrics Editorial Board Member, Stephen Harris MD, MS, shares his expert perspective on a new article from our July issue. To learn more about Dr. Harris and his work in pediatric medicine, check out our Contributors page.

By: Stephen Harris, MD, MS

child wearing helmet
Photo by Abhisek Sarda via Flickr
During pediatric residency, I used to wear a button that said “I could’a been a brain surgeon,” just to tick off the neurosurgeons. Had I only rested my brain after getting my “bell rung” during my high school hockey days, who knows? Emergency department physicians and those who provide medical care for children now have a variety of practice guidelines, management tools and questionnaires readily available to determine the severity of a concussion, track a patient’s recovery and titrate a slow and safe return to physical and cognitive activities.

Grubenhoff and colleagues, writing in the July issue of Pediatrics (doi: 10.1542/peds.2013-2988), note that 630,000 children 0 to 19 years old visit US emergency departments (ED) for concussion. Citing the evidence that the risk of persistent symptoms may be modifiable, they hypothesized that an elevated symptom score on standardized evaluation at presentation would predict an increased risk of delayed symptom resolution.

Despite careful analysis of a well conducted study, Grubenhoff’s group did not find a target score that was statistically significantly associated with delayed symptom resolution. The authors explain that other studies have shown initial acuity predicts early symptoms, but complex, pre-existing psychological factors come into play to help explain who suffers from prolonged symptoms.

In a secondary analysis, Grubenhoff’s group did find a target score that predicted a higher risk of post-concussive syndrome as defined in the new ICD-10 system. They highlight some similarities between ICD-10 and the clinical criteria they used for delayed symptom resolution, but point out that the diagnostic accuracy of the ICD-10 criteria “is a topic of scientific debate as it is both subjective and imprecise.”

The authors’ call for those working in this research area to refine the definition of post-concussive syndrome should be heeded.

Grubenhoff and colleague’s work supports a continued conservative trajectory in the management of concussion. We now have a more full awareness of the increased risk of cerebral hemorrhage following a “second hit” to the head before one has completely recovered from a concussion—for children or adolescents. We also have an enormous and growing literature on the long-term neurologic and psychiatric consequences that may face those who participate in professional sports where one objective is to savage your opponent.

At the end of the day, any patient suffering a concussion should have close outpatient follow-up and serial symptom assessment following ED discharge.

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Thursday, June 19, 2014

Abusive Head Trauma Medical Costs

Pediatrics Editorial Board Member Joann Schulte, DO, MPH, shares her expert perspective on a new article from our July issue. To learn more about Dr. Schulte and her work in general pediatrics and preventive medicine, check out her bio on our Contributors page.

By: Joann Schulte, DO, MPH

Photo by COD Newsroom via Flickr
When infants and children are abused, the long-term consequences are serious. Shaken baby syndrome or abusive head trauma can shape children’s futures negatively, and two-thirds of such children are left with significant disability, often requiring more medical care. Those children also incur significant medical expenses according to research published early released from the July issue of Pediatrics.

Using a case-control methodology, Cora Peterson and her co-authors (doi: 10.1542/ peds.2014-0117) estimated that a child who suffered abusive head trauma incurred medical expenses totaling $47,952 in the four years after the injury. For children covered by commercial insurance, estimated expenses were $38,321. Estimated expenses were higher for Medicaid patients at $56,691. Those estimated expenses did not include non-medical costs related to special education or disability.

The authors studied children aged 0 to 4 years and used regression modeling to simulate the direct medical costs. The cases and controls (five controls for each abused child) were identified in the Truven Health MarketScan database, which reports paid insurance claims and patient encounters, for the period of 2003 through 2011. Their modeling of direct medical costs was based on payments made for medical care.

Their study of the economic costs during a four-year period after abusive head trauma is a sobering analysis of the devastating consequences of what child abuse can produce.

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Tuesday, May 13, 2014

Heads Up on the Type and Duration of Post-Concussive Symptoms

By: Lewis First, MD, MS

Concurrent with the prominence of concussion as a topic that seems to be garnering more and more attention in the public media have been an array of studies attempting to help us better correctly diagnose and treat this traumatic brain injury. Our journal is no exception to the flurry of solid studies we have recently published on concussion.

Photo by Lindsay Shaver via Flickr
This week, we share a prospective cohort study by Eisenberg et al. (doi: 10.1542/peds. 2014-0158) that uses this longitudinal methodology to track children, teens, and young adults (ages 11-22) seen in an emergency department with acute concussion and then follows them for three months or until symptoms resolved.

The authors track the type of symptom encountered at the time of concussion as well as new symptoms, largely emotional, that develop during the follow-up period. They also chart the time course of symptoms to resolution providing new insight into the natural history and what to expect in the post-concussive time period.

If you want to stay ahead when it comes to knowing about concussion, this study gives you, and in turn the families of your patients, post-concussion information that will allow all of us to better monitor their recovery progress as well as what to expect in the days following the injury. Check out this article and learn more.

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Wednesday, April 23, 2014

Admit It—You Want to Try Home Oxygen for Bronchiolitis via the ED But Aren’t Sure If Benefits Outweigh Risks—Read On!

Photo by Zappy's Technology via Flickr
While hypoxia in the emergency setting usually means an inpatient admission, when there is mild hypoxia and good follow-up, perhaps sending a patients home from the emergency department on home oxygen might be an acceptable option. Yet what happens to those children sent home on extra
oxygen support?

Flett et al. (doi: 10.1542/peds. 2013-1872) studied a retrospective cohort of more than 230 consecutive patients sent home on oxygen rather than initially admitted. How these patients fared, including their need for readmission or other complications, is well-categorized in this interesting article that may change the way you manage your bronchiolitic patients.

Take a deep breath and read this study to learn more. While you’re at it, turn to a commentary by pediatric emergency medicine specialist Dr. Stephen Teach (doi: 10.1542/peds. 2014-0512) who offers his input on this study.

Are your patients with bronchiolitis being followed on home oxygen? Share your thoughts on what you do or about this study via a response to our blog, an eLetter, or our Facebook or Twitter sites.

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Tuesday, March 11, 2014

Heads Up: Two New Studies on Concussion

Evaluation of a concussion in the Emergency Department (ED) is easier said than done—and it is for that reason that the Centers for Disease Control devised an Acute Concussion Evaluation (ACE) tool to aid in evaluation and follow-up instruction. While this tool was originally designed and then modified for ED usage, only recently has its benefit been studied in a pediatric emergency setting.

Photo by UC International via Wikimedia Commons
Fortunately, we are able to share the results of implementing the ACE program in a study by Zuckerbraun et al. (doi: 10.1542/ peds.2013-2600) being early released online this week. The authors looked at ED follow-up and adherence to a stepwise return to normal activity as directed by the ACE Care Plan (part of the ACE program) both pre- and post-implementation of this program in two pediatric EDs. The results are impressive and suggest this tool should be strongly considered for your local pediatric ED facility if it isn’t already.

Adding to our battery of evaluative tools for traumatic brain injury, especially mild brain injury that persists longer than you think it should, is the Medical Symptom Validity Test (MSVT), which can help detect exaggerated problems associated with persistent symptom complaints. A second study being released this week by Kirkwood et al. (doi: 10.1542/peds.2013-3195) enrolled almost 200 patients for neuropsychological evaluation after a mild traumatic brain injury and gave them the MSVT.

Since the return to school or play depends on duration of symptoms, knowing if these symptoms are valid or not can be important in determining when a child post-concussion can go back to school or athletics. That time course might be sped up if a patient fails the MSVT, and the authors share data to support that hypothesis. If you have not heard of this test or are interested in learning more to better address the validity of your patient’s persistent symptoms after a mild concussion, head for this study and learn more.

Together, both studies introduce some evaluative tools that may enhance your evaluation of traumatic brain injuries. Are you using either or both? Do you find them useful? Share your thoughts and comments with a response to this blog of via Facebook, Twitter, or even by posting an eLetter.

Related Reading:

Tuesday, January 28, 2014

Diagnosis and Management of the Febrile Neonate in Emergency Departments in the First Month of Life: Know What To Do?

If there’s one thing we emphasize to student and resident trainees, it is to take seriously any febrile infant in their first month of life by obtaining blood, CSF, and urine cultures and admitting these infants for antibiotics pending culture results. In fact, we might say this approach is an “automatic” for fear of missing a serious bacterial infection in this very young population.

Photo by  COD Newsroom via Flickr
Yet “automatic” is not necessarily the gold standard of care as per data shared this week by Jain et al. (doi: 10.1542/
peds.2013-1820) in a fascinating cross-sectional study of febrile infants managed in 36 different pediatric emergency departments. What the authors show is substantive variation from the gold standard in that some febrile infants were sent home as a result of this variation and/or not always treated after cultures were obtained. If you want to see if febrile babies with serious infections were missed initially by varying from a standard sepsis evaluation and hospitalization and how or why their initial presentation may have led to a variation in the recommended care plan, then don’t rule-out reading this article.

If you also don’t automatically culture and admit our youngest febrile patients, let us know what the circumstances might be. Leave a comment below or on any of our social media sites including Facebook, Twitter, or even via an eLetter to our journal.

Monday, October 14, 2013

Gunshot Injuries in Children: An Emergency Services Perspective

With so much news nowadays about guns and gun violence, one wonders how much of the violence involves children and teenagers—recognizing that all it takes is one gunshot injury to anyone to raise concern.

Public Domain Photo
This week, Newgard et al. (doi: 10.1542/peds.2013-1350) share the results of a population-based retrospective cohort study involving children younger than 19 years injured by guns and seen in almost 100 hospitals spread across five regions of the western United States. The authors compared gunshot injuries with other types of injury in terms of severity, need for surgery, mortality and acute care costs, among other variables. Fortunately, while the percentage of children and teens experiencing gunshot injuries is small in this study, the variables studied all suggest that compared to other injuries, these are the most severe.

If you need further evidence to advocate for better protection of children and teens from guns, then take aim at this article and learn more. It will make you an even stronger advocate for injury prevention and reducing access of children and adolescents to these weapons.

Related Reading:

Tuesday, September 24, 2013

Establishing Quality Indicators for How We Manage Acute Pediatric Conditions: It Can Be Done!

Value-based health-care (which is rapidly becoming the driver for health-care reform) is dependent on improving quality while decreasing health-care costs.  Yet while a number of quality measures and indicators have been established to monitor for quality improvement, far fewer exist in the pediatric realm—at least until this week when Stang et al. (doi: 10.1542/peds.2013-0854), using a systematic process, have developed a set of evidence-based quality indicators that may be extremely helpful in emergency departments striving for high reliability in how they diagnose and treat children with acute pediatric conditions.  The authors used a series of questionnaires and in turn an expert panel to identify measures and the feasibility and reliability of collecting those measures.  62 measures are identified, most focused on ED processes, although there are also some that deal with outcomes with at least a third based on moderate- to high-quality evidence.

The next step is to implement these measures and make sure they truly are valid, feasible, and reliable, but to do that, it is important that you first read this article to get a better sense of what the authors have suggested and then discuss these measures with your colleagues who staff your emergency department to see if they want to use them going forward.  The authors have done some great work establishing the groundwork for some quality indicators that have been long sought-after and are now being suggested.

We welcome your comments on these indicators either through our Facebook page or an e-letter—and hope you’ll tell us whether these make sense or even if you are already using some (or all) of them.

Monday, September 2, 2013

Pulmonary Embolus in Children: They Do Occur, But Who’s at Risk?

While pulmonary embolus (PE) sits prominently on the adult differential diagnosis of acute respiratory distress, we probably don’t think of it as often as we might in our younger patients. It is perhaps for that reason that Agha et al. (doi: 10.1542/peds.2013-0126) opted to review patients in their emergency department who were diagnosed with a pulmonary embolus from 2003 to 2011.  While only 105 PEs were identified from over one million patient visits, this is still a number we can learn from—and learn we do in this article in terms of demographic risk factors as well as whether these patients would have been identified using adult exclusionary criteria or missed in their diagnosis. The authors indicate that even children with PEs are not just little adults and instead require their own specific clinical decision rules if we are going to have a high pretest probability of diagnosing and not missing a pulmonary embolus in our pediatric patients. You’ll breathe easier if you read this study to learn more.