Preparation of children for emergency medical care: a primary prevention approach

Increased emergency room use and the resulting rise in pediatric visits have prompted interest in psychological aspects of pediatric emergency care. This study evaluated the efficacy of a multicomponent hospital program designed to prepare children for emergency room visits. In Phase 1, 148 kindergarteners completed measures of medical fears and knowledge at pretreatment, posttreatment, and a 4-week follow-up. Program attenders had significantly fewer medical fears and higher medical knowledge at posttest and follow-up than control children. The program was more effective for black than white children. In Phase 2, 51 high-fear children from Phase 1 were selected randomly to attend a medical examination in an emergency room. No effects for program emerged on the observational distress measures or physiological arousal. Phase 2 children showed significantly increased medical knowledge at follow-up compared to children who did not receive the medical exam.     

Sleep Disturbance and Injury Risk in Young Children

The objective of this study was to investigate the relationship between sleep disturbance and both injury rates and injury-prone behaviors in preschool-age and early school-age children, using cross-sectional surveys of sleep disturbance (Children's Sleep Habits Questionnaire) and injury-related behaviors (Injury Behavior Checklist), and chart review of injuries. Participants were 71 patients enrolled in a pediatric clinic in a children's teaching hospital, ages 3 through 7 years, coming either for well-child care in a pediatric primary care clinic or for pediatric emergency room treatment of minor injuries. Results suggest that children with more frequent injuries had significantly more sleep problems overall, particularly anxiety around sleep, than did children with low injury rates. Children with more parent-reported injury-prone behaviors also had significantly more sleep disturbance. Daytime sleepiness-related items did not differ between injury history or injury behavior groups. Results of this study support an increased prevalence of sleep disturbances in young children with higher injury rates and more injury-prone behavior. Sleep disturbance may be a potential risk factor for increased injuries in this age group.     

Sleep disturbance and injury risk in young children

The objective of this study was to investigate the relationship between sleep disturbance and both injury rates and injury-prone behaviors in preschool-age and early school-age children, using cross-sectional surveys of sleep disturbance (Children's Sleep Habits Questionnaire) and injury-related behaviors (Injury Behavior Checklist), and chart review of injuries. Participants were 71 patients enrolled in a pediatric clinic in a children's teaching hospital, ages 3 through 7 years, coming either for well-child care in a pediatric primary care clinic or for pediatric emergency room treatment of minor injuries. Results suggest that children with more frequent injuries had significantly more sleep problems overall, particularly anxiety around sleep, than did children with low injury rates. Children with more parent-reported injury-prone behaviors also had significantly more sleep disturbance. Daytime sleepiness-related items did not differ between injury history or injury behavior groups. Results of this study support an increased prevalence of sleep disturbances in young children with higher injury rates and more injury-prone behavior. Sleep disturbance may be a potential risk factor for increased injuries in this age group.     

Comparison of emergency room asthma care to National Guidelines.

BACKGROUND: National Asthma Education and Prevention Program (NAEPP) guidelines were first released in 1991. To date there have been no studies published comparing them with actual care given. OBJECTIVE: The aim of this study was to compare the documented care given in the emergency room (ER) of an urban tertiary care hospital with 1991 NAEPP guidelines. METHODS: A total of 1858 urban emergency room records with a diagnosis of asthma or reactive airway disease were recovered in 1 year (9/95 to 8/96) from pediatric and adult patients seen in the ER. Ten percent (n = 181) of the charts were reviewed for documentation of history, assessment of severity of attack, treatment given, and disposition. RESULTS: History of present attack was documented consistently in all age groups. Nocturnal symptoms were noted in 11%, and frequency of beta agonist use in 38% of the charts. Previous ER visits, hospitalization, ICU admissions, and intubations (HCUM) were documented in 70%. Accessory muscle use was recorded in 76% of the infants and 21% of the adults. Peak flows were obtained in 31% of children and 64% of adults. Steroids were given in the ER in 59% of infants, 83% of children, and 49% of adults. Pediatric patients were referred to their primary care provider 90%, and to pulmonary or allergy clinic 4% of the time. Adults were referred to allergists or pulmonologists 32% of the time. CONCLUSION: There are significant differences in ER evaluation and treatment when compared with the 1991 NAEPP guidelines. Differences also exist between various age groups within the same institution.     

Tension headache in emergency department patients

The authors report the results of a retrospective study of the charts of 181 emergency department patients with a complaint of tension headache. Although more than half the patients appeared to be suffering from anxiety and/or depression, only 14 were seen by a psychiatrist. Anxiety was reported considerably more often than depression. Additional psychiatric training of emergency room staff and active involvement of consultation-liaison psychiatrists are suggested as means of obtaining early psychiatric intervention for headache patients with associated psychiatric problems.     

Videotaped parent education in pediatric waiting rooms

Parents in pediatric appointment clinic and pediatric emergency clinic waiting rooms were exposed to a five-minute videotaped program offering parenting tips. For half of the parents, the program was presented incidentally on a television monitor in the waiting room. The remaining half were asked to view the program individually in an adjacent room. Half of the first group actually watched the program, and those who watched learned less than half as much as did parents who viewed the program in a structured setting. In both conditions, parents rated the programs as highly appealing. Type of clinic did not affect parents' awareness, learning, or appeal ratings.     

Domestic violence screening in the emergency department of an urban hospital

Victims of domestic violence appeal to the health care system through emergency room visits for injuries related to violent episodes or for proxy care for other complaints. Screening for persons who are at high risk for violence or who are victims of violence has not been performed in emergency rooms when patients present for care, nor have all health care professionals been educated in the ways to ask the questions and assess the patients. The questions for identifying domestic violence victims have not been routinely asked on admission to the emergency department, and documentation of this information is not consistent. The purpose of this survey study was to identify the numbers and characteristics of adult victims of domestic violence who present to the emergency department of an urban community medical center during a 1 0-day period to estimate the extent of the domestic violence in the community served by the acute care facility. Findings demonstrated that emergency department staff had difficulty asking the questions, and the responsibility for the screening was relegated to the triage nurse. Questions were not asked of each adult presenting to the emergency department, and health care staff identified various reasons for their resistance. Although only 12% of persons were screened and only during the hours of 0700 through 1900, positive screens for physical abuse were found in 24.6% (n = 20) of the 81 women screened. Routine screening of all patients and sensitivity to the needs of those who have experienced domestic violence are integral to prevention and safety of those who are victimized. Injury prevention programs can then be instituted in the community with the collaborative efforts of local citizen groups and the health care facility.     

Sociodemographic and health factors influencing black and Hispanic use of the hospital emergency room

The factors influencing the increased use of emergency rooms by minorities were examined among a national sample of black and Hispanic Americans. Multivariate analysis indicated that ethnicity and age were important predictors of emergency room use. Specific health conditions also determined whether the emergency room was chosen as a health care option. Directions for future research on emergency room use are presented.     

Risk of illness after exposure to a pediatric office

To determine whether well children visiting a pediatrician's office are at risk of acquiring common communicable diseases, we conducted a prospective cohort study during the winter of 1983-1984. The occurrence of respiratory or gastrointestinal illness or fever in young children in the week after a visit to a pediatric office (office group) was compared with the occurrence of these illnesses in a similar group of children (home group) not exposed to the office during the study period. One home comparison subject was matched by age and sex to each of 127 children three years of age and under who were seen for well-child care in a private pediatric office with a common waiting room. The adjusted relative risk of the development of illness during the study week for the office group as compared with the home group was 0.95 (95 per cent confidence interval, 0.66 to 1.37), indicating no effect. We conclude that exposure to a pediatric office is not an important cause of the common infections in young children that have incubation periods of a week or less.     

Patient education materials for mental health problems in family practice: does location matter?

INTRODUCTION: This study examines how frequently family physicians display printed educational materials about mental health problems in their practices and where these materials should be located for optimal effect. METHODS: A cross-sectional observational study of pamphlet display practices in 13 family physicians' offices in Hamilton, Ontario, Canada was followed by an intervention which placed selected mental health educational materials in waiting rooms and examining rooms, and monitored the pick up rate from each location by patients. MAIN RESULTS: The study found that few mental health pamphlets were displayed by the participating physicians, that when a range of these pamphlets was made available, pamphlets on mood disorders were the most popular, and that significantly more pamphlets were picked up from examining rooms than from waiting rooms. CONCLUSIONS: We conclude that patients are interested in having access to printed materials about mental health problems, and that the optimal location is in display racks in examining rooms.     

Short-term clinical outcomes of acute treatment of childhood asthma

PURPOSE OF REVIEW: Acute exacerbations of asthma are the leading cause of emergency department visits in the pediatric patient. The present review is focused on the identification of those factors that may contribute to improving the short-term outcome of children after discharge from an emergency department visit for acute asthma. RECENT FINDINGS: Several recent studies have documented that children treated at the emergency department because of an asthma-related event present a high morbidity at 7 and 15 days after discharge, mainly associated with symptom persistence, need for rescue bronchodilator medication, and absenteeism from school or day nursery. A better control of the disease, particularly adequate outpatient follow-up and maintenance treatment with inhaled steroids, could improve short-term clinical outcomes. SUMMARY: All efforts of emergency room management of children with asthma, identification of severity of the current exacerbation episode, and intensive treatment of the acute asthma attack have usually been directed at reducing the rates of hospitalization and the return for medical care. However, according to reported data on short-term morbidity, it is necessary to define therapeutic and follow-up strategies after treatment for acute asthma and emergency department discharge. Besides standard treatment for an acute asthma exacerbation in a pediatric emergency department, action plans should include a review of the maintenance treatment of asthma to improve underlying disease control and a strong recommendation for close follow-up by the primary care pediatrician.     

Asthma in the South Bronx: Clinical and epidemiologic characteristics

This study of the adult emergency room asthma population in an urban poverty area was performed to assess and enhance the effectiveness of medical treatment and community health care delivery. The number of visits for acute asthma decreased during the 3-yr period of observation despite an annual increase in the total number of emergency room visits. This was attributed to fewer multiple visits and earlier hospitalization. An analysis of adult and pediatric patients hospitalized for asthma was also performed and revealed that asthma was responsible for 25% of pediatric and 13% of adult female medical admissions. An asthma registry of 1,329 adult patients, compiled over a 12-mo period showed a 7:3 female to male ratio of 60% Puerto Rican predominance. The identification of patients usually refractory to outpatient treatment was hindered by the constant flux in the population base as illustrated by an 85% increase in the asthma registry over the succeeding 12-mo period. Since many of these patients were previously cared for at other metropolitan institutions the creation of a centralized data system making such records available to all emergency care facilities would allow for the rapid identification of refractory patients and enhance the management of their acute episodes.     

Physician attitudes, opinions, and referral patterns: comparisons of those who have and have not taken an allergy/immunology rotation.

BACKGROUND: Interest in the field of allergy/immunology (A/I) is increasing, yet resident training programs are under pressure to shorten elective rotations such as A/I. It is unclear if there are differences between those who have and have not taken an A/I rotation. OBJECTIVE: To evaluate differences in the attitudes, opinions, and referral patterns between physicians who have and have not taken an A/I rotation. METHODS: An anonymous questionnaire was sent to 375 primary care physicians at one academic medical center. Subjects were separated into 5 cohorts based on specialty and level of training (internal medicine faculty, internal medicine resident, pediatric faculty, pediatric resident, and internal medicine-pediatric resident). RESULTS: Of the participants, 227 (61.0%) completed the survey. Compared with those who had not taken an A/I rotation, those who had taken an A/I rotation were more likely to feel they knew the types of cases seen by an allergist (75.9% vs 33.3%), to feel they knew an adequate amount about A/I (59.3% vs 19.5%), to feel they were exposed to an adequate amount of A/I during residency (64.8% vs 9.8%), to view immunotherapy as effective (70.0% vs 52.3%), and to have referred a patient to an allergist (77.8% vs 46.0%). CONCLUSIONS: There are significant differences in the attitudes, opinions, and referral patterns between physicians who have and have not taken an A/I rotation. Allergic diseases are increasing, yet residency training programs are under pressure to shorten rotations such as A/I to accommodate federally mandated work hour restrictions. The potential for inadequate care of allergic diseases may be an important issue if these trends continue.     

Outcome of long-term hospitalization for asthma in children

Children whose asthma continues to be poorly controlled with outpatient management are often referred to a long-term hospital program for care. Although these programs have been in existence since the 1950s, there has been no systematic study of their effectiveness. The purpose of the present study was to determine outcome in 103 children discharged consecutively after a long-term hospitalization. These children had both severe asthma and significant psychologic problems. Eighty-three of the 103 children had required continuous or frequent intermittent steroids for asthma control. In the year before admission, they had been hospitalized for asthma a mean of 2.6 times for 11.8 days and had had 4.6 visits to emergency rooms and 6.6 visits to physician offices for acute wheezing. Use of medical resources for asthma decreased significantly in the year after long-term hospitalization compared to the year before hospitalization (hospitalization: -34%, p less than 0.0001; hospital days: -39%, p less than 0.0002; emergency room visits: -46%, p less than 0.00001; physician office visits for acute asthma, -42%; p less than 0.00001; and a composite score giving increasing weight to more intensive and costly care: -30%, p less than 0.0001). Long-term hospitalization for children with asthma not responsive to outpatient management is associated with improvement in their use of medical resources.     

Recognition of depression and anxiety by primary physicians

Ninety-five patients completed rating scales for anxiety and depression prior to their first visit to a primary care physician. Test scores were provided selectively to the physicians, and the medical charts were checked later for entries relating to anxiety or depression. Two thirds of the patients scored in the abnormal range on at least one scale. Physicians noted depression on charts at appropriate levels (27% of patients), but anxiety was much less frequently noted (9%). Chart notations (primarily of depression) were much more common for patients scoring high in both anxiety and depression. Informing physicians of either anxiety or depression scores did not change their rate of recognition of these problems. However, those informed of scores on both rating scales made substantially fewer chart notations.     

Rapid sequence intubation (RSI) in a patient with severe head injury on the island--a case report and review of the literature

A significant proportion of acute airway management occurring outside the operating room is being performed by non-anesthesiologists. Rapid sequence intubation (RSI) as a modification of endotracheal intubation (EI) has been recognized as a core procedure within the domain of emergency physician. The technique is termed rapid sequence because it involves simultaneous induction of sedation and neuromuscular blockade, usually with succinylcholine. The method is very successfully used by trained non-anesthesiologists, physicians and ambulance paramedics in western countries, when traumatized patients are agitated and combative, uncooperative, hypoxic, hemodinamically unstable or have an increased risk of aspiration. EI is more difficult to perform in these patients and it can additionally aggravate their condition. A case is presented of a 21-year-old man with traumatic head injury and agitation on the island of Korcula, in whom RSI was succesfully performed to facilitate intubation. The standard protocol of RSI is shown where pharmacologic adjuncts to intubation are applied after the neccesery preparation. Some specific problems in the emergency care of severely injured patients on the island of Korcula are pointed out, suggesting the need to improve the education of physicians working in emergency medicine with the introduction of specialization in emergency medicine. It is an imperative to proceed with the implementation of recent programs with the purpose of emergency medical service improvement in the country, especially on distant islands.     

Implementation of clinical guidelines through an electronic medical record: physician usage, satisfaction and assessment

CONTEXT: We developed and evaluated the Emergency Department Expert Charting System (EDECS) to provide real-time guidance regarding the care of low back pain in adults, fever in children, and occupational exposure to blood and body fluids in health care workers, by embedding clinical guidelines within an electronic medical record. OBJECTIVE: To describe the behaviors and attitudes of physicians who used EDECS. DESIGN: Pre-post questionnaires were used to assess physician attitudes. Time studies of the intervention phase were observational, using clocks embedded in the software. PARTICIPANTS: One hundred and forty two residents and interns in emergency, pediatric, internal, and family medicine and patients with the above-mentioned complaints. MAIN OUTCOME MEASURES: Physician utilization of EDECS, time spent using EDECS, physician satisfaction and beliefs. RESULTS: Eighty four percent of the 142 eligible physicians used EDECS at least once. Five hundred and ninety one of 789 (75%) eligible cases were completed using EDECS. Median session time decreased from 12 min for session 1, to 5.5 min for sessions 16 and above. Physicians generally agreed that care with EDECS was better than standard care, particularly with respect to documentation. There was, however, considerable heterogeneity in belief among complaints. CONCLUSIONS: These data illuminate both the potentials of computer-assisted decision making and the need for context-specific approaches when attempting to implement guidelines.     

Understanding delay in treatment for first-episode psychosis

BACKGROUND: A lengthy delay often occurs between the onset of symptoms of psychotic disorders and initiation of adequate treatment. In this paper we examine the extent to which this represents a delay in individuals contacting health professionals or a delay in receiving treatment once such contact is made. METHOD: Pathways to care were examined in 110 patients of the Prevention and Early Intervention Program for Psychosis in London, Canada. Data were collected using structured interviews with patients, family members, consultation with clinicians and review of case records. RESULTS: Family physicians and hospital emergency rooms were prominent components of pathways to care. Both delay to contact with a helping professional and delay from such contact to initiation of adequate treatment appear to be about equally important for the sample as a whole, but some individuals appear to be at risk for particularly lengthy delay in the second component. Individuals with younger age of onset, or who had initial contact with professional helpers before the onset of psychosis and were being seen on an ongoing basis at the time of onset of psychosis, had longer delays from first service contact after onset to initiation of adequate treatment. The greater delay to treatment for those being seen at the onset of psychosis does not appear to reflect differences in age, gender, symptoms, drug use or willingness to take medication. CONCLUSIONS: Interventions to reduce treatment delay should increase the public's awareness of the symptoms of psychotic illness and the need to seek treatment, but of equal importance is the education of service providers to recognize such illness and the potential benefits of earlier intervention.