Emergency Care Connect: Extending Pediatric Emergency Care Expertise to General Emergency Departments Through Telemedicine

Increasingly, children with common and lower-acuity conditions are being transferred from general emergency departments (EDs) to pediatric centers for subspecialty care. While transferring children with high-risk conditions has benefit, transferring children with common conditions may expose them to redundant care and added costs. Emergency Care Connect (ECC) is a novel telemedicine program that uses videoconferencing to connect general ED and urgent care providers to pediatric emergency medicine physicians with the goal of keeping children in their communities for definitive care, when safe and feasible. ECC objectives are to: 1) facilitate transfer decision-making for children receiving care in general ED and urgent care sites and 2) increase access to pediatric providers for real-time management, regardless of disposition. In its first 20 months, ECC partnered with 4 general EDs and 1 urgent care location, which together made 1327 contacts with our pediatric center, of which 202 (15%) became ECC consultations for 200 unique patients. Of those consultations, 71% patients remained locally for treatment and 25% experienced a care plan change. Overall, ECC was rated highly by surveyed families and providers. Barriers to implementation, such as lack of familiarity with telemedicine and fears of changes in workflow, were overcome with strong institutional support and frequent, sustained stakeholder engagement. With greater adoption of this model, ECC and programs like it have the potential to allow more children to be treated in their communities, minimize preventable transfers, and reserve beds in children's hospitals for those with potentially higher risk and more medically complex conditions.     

Pediatric Agitation in the Emergency Department: A Survey of Pediatric Emergency Care Coordinators

ObjectiveAcute agitation episodes in the emergency department (ED) can be distressing for patients, families, and staff and may lead to injuries. We aim to understand availability of ED resources to care for children with acute agitation, perceived staff confidence with agitation management, barriers to use of de-escalation techniques, and desired resources to enhance care.MethodsWe conducted a survey of pediatric emergency care coordinators (PECCs) in EDs in Massachusetts, Rhode Island, and Los Angeles County, California.ResultsPECCs from 63 of 102 (61.8%) EDs responded. PECCs reported that ED staff feel least confident managing agitation due to developmental delay (DD) or autism spectrum disorder (ASD) (52.4%). Few EDs had a separate space to care for children with mental health conditions (22.5%), a standardized agitation scale (9.6%), an agitation management guideline (12.9%), or agitation management training (24.2%). Modification of the environment was not perceived possible for 42% of EDs. Participants reported that a barrier to the use of the de-escalation techniques distraction and verbal de-escalation was perceived lack of effectiveness (22.6% and 22.6%, respectively). Desired resources to manage agitation included guidelines for medications (82.5%) and sample care pathways (57.1%).ConclusionsED PECCs report low confidence in managing agitation due to DD or ASD and limited pediatric resources to address acute agitation. Additional pediatric-specific resources and training, especially for children with DD or ASD, are needed to increase clinician confidence in agitation management and to promote high-quality, patient-centered care. Training programs can focus on the early identification of agitation and the effective use of non-invasive de-escalation strategies.     

Prospective multicenter study of relapse after treatment for acute asthma among children presenting to the emergency department

OBJECTIVE: Single-center studies have reported varying relapse rates after treatment of patients with acute asthma. We determined the relapse rate after emergency department (ED) treatment in a cohort of children. DESIGN: This was a prospective inception cohort study performed during 1997-1998. SETTING: The study was performed in 44 EDs including both general and pediatric centers. PATIENTS: Children (n = 1184) aged 2 to 17 years who had been admitted to EDs, with acute asthma restricted to 881 patients discharged from the ED. MAIN RESULTS: Two weeks after discharge, families were telephoned to determine relapse. Follow-up data were available for 762 (86%) of the children with a 10% incidence of relapse. On univariate analysis several factors were associated with relapse including current medications and markers of asthma severity. On multivariate analysis the factors associated with relapse were age (OR 1.4 per 5-year increase), use of second-line asthma medications (OR 3.7), exposure to cigarette smoke (OR 0.5), and ED visits within the past year (OR 1.2 per 5 ED visits). CONCLUSIONS: The incidence of relapse among children is lower than that observed among adults and varies with age. Other risk factors such as frequent ED visits are likely markers of chronic asthma severity. Further research should focus on ways to decrease the relapse rate among patients at high risk.     

Overcrowding crisis in our nation's emergency departments: is our safety net unraveling?

Emergency departments (EDs) are a vital component in our health care safety net, available 24 hours a day, 7 days a week, for all who require care. There has been a steady increase in the volume and acuity of patient visits to EDs, now with well over 100 million Americans (30 million children) receiving emergency care annually. This rise in ED utilization has effectively saturated the capacity of EDs and emergency medical services in many communities. The resulting phenomenon, commonly referred to as ED overcrowding, now threatens access to emergency services for those who need them the most. As managers of the pediatric medical home and advocates for children and optimal pediatric health care, there is a very important role for pediatricians and the American Academy of Pediatrics in guiding health policy decision-makers toward effective solutions that promote the medical home and timely access to emergency care.     

Improving Asthma Outcomes in Children: From the Emergency Department and Into the Community

Asthma is responsible for significant disease burden and health care cost. A heterogeneous disease with significant environmental, genetic, and economic risk factors, asthma disproportionally affects the most vulnerable children. Effective strategies to improve individual asthma control rely on a multidisciplinary, cross-sector approach. The emergency department (ED) is a critical resource to identify children at risk for high morbidity and mortality from asthma. It is imperative to identify barriers to asthma control in the ED while being mindful of transitions and care coordination, especially as the United States moves to value-based reimbursement of health care. We review recent literature on ED-based interventions, present data on the importance of addressing housing and involving schools, and conceptualize an ideal medical home for asthma. We also provide examples of how our own institution has developed programs across sectors to improve asthma outcomes in children.     

Pediatric Quality Improvement Engagement In The Community Setting

Providing safe, high quality care to pediatric patients is a core goal for all healthcare systems. To this end, robust quality improvement and patient safety methodologies have been developed to improve pediatric patient care in academic medical centers. However, given that the majority of pediatric patients are first seen in emergency departments (EDs) in community hospitals rather than academic pediatric medical centers, there is an urgent need to adapt these methodologies to the community ED environment. In this review, we begin to address these issues by looking to successful quality improvement and patient safety initiatives for lessons that can be adapted to the unique challenges and opportunities encountered in community healthcare settings.     

Trends and challenges in international pediatric emergency medicine

PURPOSE OF REVIEW: Pediatric emergency care internationally is practiced in a wide variety of local contexts, and the quality of care varies. International pediatric emergency medicine refers to the spectrum of care provided to children with serious illnesses and injuries globally. This article serves as the first of its kind to characterize current trends and challenges in this area. RECENT FINDINGS: Current trends in international pediatric emergency medicine include international dissemination of pediatric emergency medicine guidelines, pediatric-specific disaster relief training, increasing numbers of pediatric emergency medicine research collaboratives, interest groups and training programs, and increasing numbers of spaces dedicated to pediatric emergency care. Current challenges to the field include inequalities in access to medical research and information, various nonmedical barriers and lack of reports describing approaches to the delivery of pediatric emergency care. SUMMARY: While there are many recent advances in the state of pediatric emergency medicine internationally, there still exist many barriers to the improvement in its quality. Many of these obstacles are not specific to pediatric emergency medicine, but reflect overall disparities between the developing and developed worlds. One first step to overcoming pediatric emergency medicine practiced in isolation is a formal organization of the field of international pediatric emergency medicine.     

Telehealth as a Tool for Quality Improvement in the Care of Pediatric Patients in Community Emergency Departments

Nearly 90% of pediatric emergency care is provided in a general emergency department (ED) that serve both adults and children. Many children in the United States do not live near an ED with a high level of pediatric readiness and many children are transferred to dedicated pediatric centers. Telemedicine provides an opportunity to impact care delivery systems to allow for children to be treated closer to home while maintaining high quality care. In this article, we will explore opportunities to use telemedicine in the emergency department and discuss incorporating quality improvement methodology to increase utilization of telehealth services.     

Pediatric Quality Improvement in the Prehospital and Emergency Department Worlds: Tools and Examples to Guide Change

National organizations and national surveys have highlighted the gap in quality pediatric care and preparedness in emergency departments (EDs) over the last 20 years. The objective of this review is to provide a framework, summary, and list of common resources to guide general EDs in the use of proven quality improvement tools and resources towards meaningful improvement in pediatric care in the their institution. This review also highlights organizations, such as the Emergency Medical Services for Children Innovation and Improvement Center, that serve as leaders and repositories for collaborative work and expertise to improve pediatric emergency care anywhere in the United States.     

Quality Improvement–Driven Reductionin Countywide Medicaid Acute AsthmaHealth Care Utilization

Objective

This study evaluates the impact of a coordinated effort by an urban pediatric hospital and its associated accountable care organization to reduce asthma-related emergency department (ED) and inpatient utilization by a large, countywide Medicaid patient population.

Predictors of health care utilization of children with asthma in the community

The aim of this study was to assess the pattern of use of health care services among children with asthma symptoms within the community, and assess groups at increased risk of emergency department (ED) visits or hospital admissions (HA). Using International Study of Asthma and Allergies in Childhood phase II protocol, information about asthma management and utilization of health care services was collected by parental questionnaire in a community-based random sample of 5–7- and 9–11-year-old children (n = 11,094) in Dresden and Munich. Only 11.2% of children with current wheeze did not utilize any health care facility or consultation for their asthma symptoms in the 12 months prior to survey, while 86.2%, 12.3%, and 3.6% had at least one asthma related physician's consultation, ED visits, or HA, respectively. Predictors of ED visits and HA among current wheezers were: younger age, male gender, speech-limiting wheeze, level of exposure to environmental tobacco smoke. In addition, children of low socioeconomic status were more likely to have ED visits because of their asthma. Childhood asthma is a major public health problem in Germany leading to substantial morbidity and utilization of health care services. Exposure to tobacco smoke comes out as the major modifiable risk factor related to asthma morbidity in children.     

Emergency medical services for children: the New Jersey model

Identification of specific facilities within a community for the emergency department (ED) treatment of children is a traditional component of Emergency Medical Services for Children systems. In such models, these Emergency Departments Approved for Pediatrics are the preferred EDs to receive patients from Emergency Medical Services providers. This article examines an alternative model developed in New Jersey in which every ED in the state is required by regulation to meet the standards of a traditional Emergency Departments Approved for Pediatrics. The New Jersey model leads to more accessible care and more rapid stabilization of children regardless of their mode of delivery to the ED.     

Emergency department overcrowding and children

Emergency department (ED) overcrowding has been a serious issue on the national agenda for the past 2 decades and is rapidly becoming an increasingly significant problem for children. The goal of this report is to focus on the issues of overcrowding that directly impact children. Our findings reveal that although overcrowding seems to affect children in ways similar to those of adults, there are several important ways in which they differ. Recent reports document that more than 90% of academic emergency medicine EDs are overcrowded. Although inner-city, urban, and university hospitals have historically been the first to feel the brunt of overcrowding, community and suburban EDs are now also being affected. The overwhelming majority of children (92%) are seen in general community EDs, with only a minority (less than 10%) treated in dedicated pediatric EDs. With the exception of patients older than 65 years, children have higher visit rates than any other age group. Children may be at particularly increased risk for medical errors because of their inherent variability in size and the need for age-specific and weight-based dosing. We strongly recommend that pediatric issues be actively included in all future aspects of research and policy planning issues related to ED overcrowding. These include the development of triage protocols, clinical guidelines, research proposals, and computerized data monitoring systems.     

Patient complaints in a pediatric emergency department: averting lawsuits

All emergency departments (EDs) receive complaints from patients and their families. Consumers of pediatric emergency care are becoming more astute about the care they receive, and the malpractice climate is rapidly changing. In order to improve patient care services and reduce the frequency of lawsuits, it is crucial that pediatric emergency medicine physicians become facile at preventing and managing such complaints. All ED physicians should have a well-defined complaint management process in place. Lessons learned from the complaints should be shared with the ED health care providers. Complaints can illustrate the deficiencies in the provision of care and serve as an opportunity for improvement.     

Pediatric and adolescent mental health emergencies in the emergency medical services system

Emergency department (ED) health care professionals often care for patients with previously diagnosed psychiatric illnesses who are ill, injured, or having a behavioral crisis. In addition, ED personnel encounter children with psychiatric illnesses who may not present to the ED with overt mental health symptoms. Staff education and training regarding identification and management of pediatric mental health illness can help EDs overcome the perceived limitations of the setting that influence timely and comprehensive evaluation. In addition, ED physicians can inform and advocate for policy changes at local, state, and national levels that are needed to ensure comprehensive care of children with mental health illnesses. This report addresses the roles that the ED and ED health care professionals play in emergency mental health care of children and adolescents in the United States, which includes the stabilization and management of patients in mental health crisis, the discovery of mental illnesses and suicidal ideation in ED patients, and approaches to advocating for improved recognition and treatment of mental illnesses in children. The report also addresses special issues related to mental illness in the ED, such as minority populations, children with special health care needs, and children's mental health during and after disasters and trauma.     

The relationship of fall school opening and emergency department asthma visits in a large metropolitan area

BACKGROUND: Asthma morbidity is seasonal, with the fewest exacerbations occurring in summer and the most exacerbations in early fall. OBJECTIVE: To determine if the fall increase in pediatric asthma emergency department (ED) visits is related to the school year start. DESIGN: Time-series study of daily asthma ED visits taken from an administrative claims database for the years 1991 to 2002. SETTING: Eleven municipal hospitals in New York City, NY.Patients Emergency department visits with asthma as the primary diagnosis among children aged 2 to 4, 5 to 11, and 12 to 17 years and adults with asthma aged 22 to 45 years as comparative group.Main Outcome Measure Rate of asthma ED visits after the September school opening compared with before the opening, during a 60-day window of each year. The delayed effect of school opening was examined by the lagged school-opening indicator for lag 0 through 9 days. The model adjusted for factors that may influence morbidity. There were 86 731 ED visits within the study period. RESULTS: Asthma ED visits for children aged 5 to 11 years were significantly associated with school opening day, with the highest lagged rate ratio being 1.46 (95% confidence interval [CI], 1.29-1.65). For children aged 2 to 4 years, the highest rate ratio was 1.19 (95% CI, 1.06-1.35), and for children aged 12 to 17 years, the highest lagged rate ratio was 1.13 (95% CI, 0.98-1.31). The rise in adult ED visits following school opening was less substantial, with the highest lagged rate ratio being 1.07 (95% CI, 1.00-1.14). CONCLUSION: The start of the September school year was associated with increases in pediatric asthma ED visits, particularly among grade school children.     

Puerto Rican Families’ Experiences of Asthma and Use of the Emergency Department for Asthma Care

Puerto Ricans have been found to have higher asthma prevalence rates than non-Hispanic whites, blacks, and all other Hispanic subgroups. They also have the highest rates of emergency department (ED) use for the management of their asthma. Using a hermeneutic phenomenological approach, the aim of this study was to describe the lived experience of Puerto Rican families caring for their child's asthma and using the ED for asthma care. Six themes were generated from in-depth interviews with 10 Puerto-Rican caregivers: (1) The Folklore of Asthma, (2) Culture and the Medicine Woman, (3) In Awe of Asthma, (4) Praying to God, (5) The Decision–Time to Go, and (6) The ED Environment. The findings emphasize the necessity of establishing and maintaining a therapeutic partnership between primary care providers and families of children with asthma. The results may be used as a foundation for understanding motivations for seeking asthma care in the ED.     

Care of children in the emergency department: guidelines for preparedness

Children requiring emergency care have unique and special needs. This is especially so for those with serious and life-threatening emergencies. There are a variety of components of the emergency care system that provide emergency care to children that are not limited to children. With regard to hospitals, most children are brought to community hospital emergency departments (EDs) by virtue of their availability rather than to facilities designed and operated solely for children. Emergency medical services (EMS) agencies, similarly, provide the bulk of out-of-hospital emergency care to children. It is imperative that all hospital EDs and EMS agencies have the appropriate equipment, staff, and policies to provide high quality care for children. This statement provides guidelines for necessary resources to ensure that children receive quality emergency care and to facilitate, after stabilization, timely transfer to a facility with specialized pediatric services when appropriate. It is important to realize that some hospitals and local EMS systems will have difficulty in meeting these guidelines, and others will develop more comprehensive guidelines based on local resources. It is hoped, however, that hospital ED staff and administrators and local EMS systems administrators will seek to meet these guidelines to best ensure that their facilities or systems provide the resources necessary for the care of children. This statement has been reviewed by and is supported in concept by the Ambulatory Pediatric Association, American Association of Poison Control Centers, American College of Surgeons, American Hospital Association, American Medical Association, American Pediatric Surgical Association, American Trauma Society, Brain Injury Association Inc, Emergency Nurses Association, Joint Commission on Accreditation of Healthcare Organizations, National Association of Children's Hospitals and Related Institutions, National Association of EMS Physicians, National Association of EMTs, National Association of School Nurses, National Association of State EMS Directors, National Committee for Quality Assurance, and Society for Academic Emergency Medicine.