Hospital and emergency department use by young low-income children

BACKGROUND: Limited data are available concerning determinants of health care service usage by low-income young children. OBJECTIVES: To explore predictors of hospitalization and emergency department (ED) use by young children of low-income families by using the Aday and Andersen Access Framework. METHODS: Low-income women (n = 474) with a child younger than 6 years completed a structured face-to-face interview at human service offices or Women, Infants, and Children (WIC) clinics in four central Ohio counties. Women were considered low-income if they or their child were Medicaid eligible or uninsured. Data were collected for both the mother and the index child on sociodemographic status, health services use, health status, and access to care. RESULTS: Fifteen percent of the children had been hospitalized the previous year, and half had an ED visit. Hospitalization was significantly related to maternal hospitalization the previous year (OR = 2.5), child age younger than 1 year old (OR = 2.1) and more than two chronic conditions (OR = 2.2). Maternal ED usage in the last year (OR = 2.2), Medicaid fee for service plan (OR = 1.7), and rural residence (OR = 2.0) were predictive of ED use. CONCLUSIONS: Predisposing characteristics (maternal hospital/ED use) were predictive of both hospitalization and ED use by the index child. Enabling characteristics (fee-for-service Medicaid plan, rurality) were only predictive of ED use, and need characteristics (child's health) were only predictive of hospitalization. Further research to explore linkages between maternal and child use of health care services as well as the effect of changes in health care access, managed care, and other innovations on hospitalization and ED use in young, low-income children is recommended.     

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.     

Who should nurse children requiring emergency care?

There are constant challenges in developing a workforce fit to deliver care to children and young people requiring emergency or urgent care. These challenges are often compounded when the care setting for children and young people is within a general Emergency Department. This paper will review contemporary issues around who should deliver emergency care to children in these settings; reasoned debate is required to ensure that we have a workforce fit for purpose.     

Chest pain in a 12-year-old boy: when is it a harbinger of poor outcome?

Chest pain is usually a benign presentation in children who present to emergency departments (ED) or primary care centers. Unlike adults, where chest pain is commonly due to cardiac causes, in children the cause is more likely secondary to non-cardiac causes. Here we present a case of a child known to have hyper-eosinophilic syndrome (HES) who presented with sudden onset of chest pain and had a rapidly progressive and fatal outcome in the ED. We discuss the ED approach to the child with chest pain and review acute myocardial infarction (AMI) in children.     

Restraint in the care of children

As a nursing student on an emergency department (ED) placement, the author of this article experienced personal and professional conflict while restraining a child during a clinical procedure. This experience should be familiar to ED nurses, many of whom, however, lack confidence in the use of restraint techniques. This article describes how nurses can acquire this confidence while understanding the practical and legal implications of restraint. The article emphasises the importance of involving children and their families or carers in therapeutic partnerships before consent to restraint is sought. It also presents three levels of holding.     

Suicidal Behavior in Children Younger than Twelve: A Diagnostic Challenge for Emergency Department Personnel

Suicide is one of the leading causes of death in children younger than 12 years and is the fourth leading cause of death in 12 year olds. Increasing numbers of young children now present to the emergency department (ED) with mental health issues, and ED personnel must determine the most appropriate disposition options for these children, sometimes without the assistance of specialty mental health services. Much of the present body of literature describing suicidality fails to separate children from adolescents for analysis and discussion. This article reviews relevant literature pertaining to suicidal thoughts and behaviors in young children and discusses problems with available data, as well as epidemiology, risk factors, typical motivations, methods, assessment, and disposition for these patients. Suicidal children younger than 12 years are often clinically different from suicidal adolescents and adults and may require unique assessment and disposition strategies in the ED. A child who has ideation without a clear plan, or has made an attempt of low lethality, can sometimes be discharged home, provided that a supportive, responsible caregiver is willing to monitor the child and take him or her to outpatient mental health appointments. If the home environment is detrimental, or the child has used a method of high potential lethality, inpatient treatment is the most appropriate course of action. Mental health specialty services, when available, should be used to help determine the most appropriate disposition.     

Initial assessment of young people in the emergency department

One of the most important aspects of care for children in emergency departments (EDs) is the initial assessment of their conditions and circumstances. Paediatric nurses, or other nurses who have had adequate training and skills in the care of children and younger people, should use the appropriate tools to undertake these assessments so that they can identify and manage children's physical, mental or social problems. This article discusses the use of such tools in the initial assessments of children at Ipswich Hospital NHS Trust ED, and how this use has improved practice while raising the profile of paediatric emergency care.     

Lifestyle limitations of children and young people with severe cerebral palsy: a population study protocol

Title. Lifestyle limitations of children and young people with severe cerebral palsy: a population study protocol Aim. This paper is a presentation of a study protocol to establish the prevalence of orthopaedic problems (hip dislocation, pelvic obliquity, spinal deformity and contractures) and their impact on pain, function, participation and health in a population of children and young people with severe cerebral palsy. Background. Cerebral palsy is the commonest cause of motor impairment in childhood and is associated with life‐long disability. An estimated 30% of people with cerebral palsy have severe forms and are non‐ambulant. Although the underlying neurological damage is not amenable to correction, many health services are dedicated to providing therapeutic and adaptive support to help people with the condition reach their potential. Method. A cross‐sectional survey of children and young people, aged 4–25 years with severe, non‐ambulant cerebral palsy as defined using the Gross Motor Function Classification System (Levels IV and V). Study participants will be identified from a pre‐existing, geographically defined case register and recruited via a healthcare professional known to them. Two assessments will be undertaken: one involving parents/carers at home and using questionnaires; the other involving the child/young person ideally in one of three settings and including X‐rays if clinically indicated. Discussion. This study will contribute to our knowledge of the history and epidemiology of orthopaedic problems in children and young people with cerebral palsy and how these problems accumulate and impact on participation, health and well‐being. The study will also identify unmet need and make recommendations for good practice in relation to the orthopaedic care and management for people with severe cerebral palsy.     

Prescribing for children

Many children receive urgent care within emergency departments. Children are at increased risk from the use of medicines for a number of reasons, including the need to calculate a weight or age-based dose or administration of a fraction or proportion of an adult formulation of medicine. Aspects of good practice from the English National Service Framework (NSF) for Children, Young People and Maternity Services are highlighted. The importance of good medicines reconciliation is discussed. Websites that support emergency care practitioners to address medicines adherence and counselling of parents and children on use of medicines are presented. The drug related needs of children and young people must be assessed on an individual basis. Guidelines are outlined to support safe prescribing and medicines administration.     

End-of-life Models and Emergency Department Care

Many people die in emergency departments (EDs) across the United States from sudden illnesses or injuries, an exacerbation of a chronic disease, or a terminal illness. Frequently, patients and families come to the ED seeking lifesaving or life-prolonging treatment. In addition, the ED is a place of transition-patients usually are transferred to an inpatient unit, transferred to another hospital, or discharged home. Rarely are patients supposed to remain in the ED. Currently, there is an increasing amount of literature related to end-of-life care. However, these end-of-life care models are based on chronic disease trajectories and have difficulty accommodating sudden-death trajectories common in the ED. There is very little information about end-of-life care in the ED. This article explores ED culture and characteristics, and examines the applicability of current end-of-life care models.     

A nursing intervention to increase compliance in otitis media patients

This study was conducted to evaluate two forms of a clinical nursing intervention based on the Health Belief Model (HBM) and designed to increase compliance among 59 otitis media (OM) patients (14 adults and 45 children) visiting an emergency department (ED). Subjects (adult patients or caretakers of child patients) who received an HBM clinical intervention administered by a nurse in the ED, and HBM phone intervention 2 to 4 days after the ED visit, or both interventions were much more likely than control subjects to comply with a follow-up referral appointment. Both the clinical and phone interventions were designed to increase perceived susceptibility to complications of the OM, seriousness of the complications, and benefits and costs of action. Other factors predicting compliance included subjects' unmet needs for child care, perceived seriousness of the OM, and degree of knowledge of the etiology, pathophysiology, and management of OM.     

Children in Accident and Emergency

The purpose of this paper is to examine the many issues surrounding the care of children within Accident and Emergency (A & E) departments. A review of relevant literature reveals the principles that are pertinent to the care of the child in hospital and specifically within an A & E department. Theories of child development are introduced and discussed in relation to nursing care of children. The reflective cycle is used to examine two critical incidents. The analysis of these events allows further scrutiny of the ideas relating to the care of children and illustrates the way in which such ideals can be used to guide practice. The author concludes that a sound knowledge of the developmental process of the child, and an understanding of the particular issues relevant to the care of the child within the accident and emergency environment can ensure optimum care for each child and their family.     

Family-centred services within Accident and Emergency Departments

The concept of children and their families receiving family-centred care when the child is unwell is not new. Family-centred care has been examined extensively within children's nursing curricula. However, recent policy documents have suggested that all child health services, not just children's nursing, should be family-centred. The subtle differences between family-centred care and family-friendly care are identified. The skills for working with children are also examined in turn for all ED nurses. Whilst many ideas may not initially appear to be new or therefore innovative, a careful evaluation encourages individuals to rethink the services that they currently offer to children and their families.     

Over-the-counter cough and cold medication use in young children

During a 2-year period from 2004 and 2005, emergency departments treated over 1,500 children under the age of 2 years for adverse events related to over-the-counter (OTC) cough and cold medication use; these incidents include 3 infant deaths. The risk of overdose, incorrect dosing and adverse events is increased in young children due to the greater number of colds they acquire each year. Lack of evidence to support the use of OTC medications in young children is well documented in the literature; however, people continue to use OTC medications with young children. The common cold is generally a mild, self-limited illness that usually improves with time. Recommended care and treatment for the common cold includes symptomatic treatment. This article presents and reviews the available evidence regarding the use of OTC cough and cold medications for pediatric healthcare providers. This review of the evidence will be helpful for healthcare providers to minimize risks to young children who intentionally or unintentionally ingest these medications and to educate child caregivers regarding proper use of OTC cough and cold medications with children.     

The role of specialist nurses in improving treatment adherence in children with a chronic illness

Adherence to medical treatment is an ongoing challenge for families and young people with chronic medical conditions. One factor that is likely to influence treatment success is the quality of professional relationships both within the health care team and between the family, child and professionals. This paper explores the topic of professional relationships and adherence and provides an example of how a multidisciplinary team can improve the health and quality of life of paediatric patients. More specifically, the paper argues for the crucial role of the specialist nurse in supporting patients and their relationships with the health care team.     

Safety of Paramedics with Extended Skills

Background:  The role of paramedics with extended skills is evolving, enabling them to assess and treat patients in the community. A United Kingdom service led by extended-role paramedic practitioners (PPs) is aimed at managing minor acute illness and injury among older people in the home when appropriate, avoiding unnecessary transfer to the emergency department (ED).
Objectives:  The objectives were to evaluate the safety of clinical decisions made by PPs operating within the new service.
Methods:  As part of a cluster-randomized controlled trial, patients aged >60 years contacting the emergency medical services (EMS) with a minor injury or illness were included in the study. The safety of the new PP intervention was compared with standard practice of EMS transfer and ED treatment. Outcomes included unplanned ED attendance within 7 days of the index episode. Clinical records were rated independently by two senior ED clinicians to identify related episodes, avoidable subsequent episodes, and suboptimal care.
Results:  Of the 2,025 patients included in this analysis, 219 (10.9%) went on to have an unplanned ED attendance within 7 days. Of these, 162 (74.0%) re-presented with a condition related to their index episode. The independent raters agreed on suboptimal care 83.4% of the time. There were 16 agreed upon episodes related to suboptimal care (0.80%). No significant differences were found between intervention and control groups in relation to re-presentation at hospital within 7 days for a related condition or rates of assessed suboptimal care.
Conclusions:  This study suggests that appropriately trained paramedics with extended skills treating older people with minor acute conditions in the community are as safe as standard EMS transfer and treatment within the ED.     

Association of injury visits in children and child maltreatment reports

Injuries are a leading cause of childhood morbidity and are also common manifestations of child maltreatment, especially among young children. In an effort to determine whether injury-related Emergency Department (ED) visits among children aged 0 to 4 years were associated with child maltreatment reports, we identified all children with at least one injury-related ED visit in Missouri during 2000. Data on these injured children were linked to Missouri Child Protective Services (CPS) child abuse and neglect reports for 2000 and 2001. There were 50,068 children with at least one injury-related ED visit. Using children with one injury-related ED visit as the reference category, we calculated the relative risk of having a CPS report (or a substantiated report) for children with two, three, and four or more ED visits before a CPS report (or substantiated report). Compared to children with one visit, children with two visits were more likely to have a CPS report (relative risk [RR] 1.9; 95% confidence interval [CI] 1.8-2.0) and a substantiated report (RR 2.5; 95% CI 2.1-2.9). For children with four or more visits, the relative risk of a report and substantiated report was 3.8 (95% CI 3.0-4.7) and 4.7 (95% CI 2.4-9.2), respectively. Children with two or more injury-related ED visits in 1 year are more likely to be reported for child maltreatment and to have a substantiated report.     

Physician assistants in Australasian emergency departments

A physician assistant (PA) is a university qualified health professional who's primary role is to provide medical care under the direction and supervision of medical staff. This is a new profession in Australasia. The PA is well suited to working in both rural, regional and urban settings that deliver emergency medical care. A perspective is presented on their role and scope of practice within the Australasian emergency care system supported by some early findings from their use in a tertiary ED.     

An evidence-based eating disorder program

The Children's Hospital of Denver has an internationally renowned outpatient-inpatient treatment program for children, adolescents, and young adults with eating disorders (EDs). A unique feature of this ED program is its inpatient location on a medical unit. The nurses are medically trained, yet their patients with EDs have complex emotional and psychological problems. To address the special needs of these patients, a child life specialist worked in collaboration with other members of an ED health care team to create a program better serving ED pediatric patients. An evidence-based approach was used to drive this program. The child life specialist queried other health care facilities for best practice ideas, searched the literature, and analyzed unit-based ED data to design a program matching the needs of the patients.     

Distances to Emergency Department and to Primary Care Provider's Office Affect Emergency Department Use in Children

Objectives:  Patients of all ages use emergency departments (EDs) for primary care. Several studies have evaluated patient and system characteristics that influence pediatric ED use. However, the issue of proximity as a predictor of ED use has not been well studied. The authors sought to determine whether ED use by pediatric Medicaid enrollees was associated with the distance to their primary care providers (PCPs), distance to the nearest ED, and distance to the nearest children's hospital.
Methods:  This historical cohort study included 26,038 children age 18 and under, assigned to 332 primary care practices affiliated with a Medicaid health maintenance organization (HMO). Predictor variables were distance from the child's home to his or her PCP site, distance from home to the nearest ED, and distance from home to the nearest children's hospital. The outcome variable was each child's ED use. A negative binomial model was used to determine the association between distance variables and ED use, adjusted for age, sex, and race, plus medical and primary care site characteristics previously found to influence ED use. Distance variables were divided into quartiles to test for nonlinear associations.
Results:  On average, children made 0.31 ED visits/person/year. In the multivariable model, children living greater than 1.19 miles from the nearest ED had 11% lower ED use than those living within 0.5 miles of the nearest ED (risk ratio [RR] = 0.89, 95% CI = 0.81 to 0.99). Children living between 1.54 and 3.13 miles from their PCPs had 13% greater ED use (RR = 1.13, 95% CI = 1.03 to 1.24) than those who lived within 0.7 miles of their PCP.
Conclusions:  Geographical variables play a significant role in ED utilization in children, confirming the importance of system-level determinants of ED use and creating the opportunity for interventions to reduce geographical barriers to primary care.