Complications After Preterm Birth: An Overview for Emergency Physicians

Neonatal intensive care unit graduates may have one or more unresolved morbidity at the time of their discharge from the NICU and may require care from multiple subspecialists. They remain at high risk for visits to the ED and subsequent rehospitalization. These infants, with their unique set of morbidities, may offer an unusual challenge and may overwhelm an ED physician unfamiliar with the various complications after preterm birth. We hope that this article will provide ED physicians with a basic understanding of some of these common complications after preterm birth.     

How ready are they? Parents of pediatric solid organ transplant recipients and the transition from hospital to home following transplant

Poor discharge transition is evidence of a gap between evidence-based practices and current health care delivery. Pediatric SOT recipients are a vulnerable population at risk of complications during the discharge transition. The aim of this study was to investigate factors associated with the transition care from hospital to home. We studied the transition experience of parents of heart, liver, or kidney recipients to identify opportunities for improvement in discharge and post-discharge care processes and outcomes. Thirty-seven parents from three different pediatric transplant centers completed questionnaires on the day of hospital discharge and three wk following hospital discharge. Care coordination was associated with readiness for hospital discharge. Readiness for hospital discharge was subsequently associated with post-discharge coping difficulty, adherence difficulty with medical follow-up, and family impact. Identifying parents who are not ready to go home provides an opportunity to offer additional support services so parents can effectively manage their child's recovery and continuing care at home.     

Psychotropic Medication Use in United States Pediatric Emergency Department Visits

Objective and BackgroundLittle is known about pediatric psychotropic medication use in the emergency department (ED), despite a rise in mental and behavioral health visits. This study describes psychotropic medication use in a nationally representative sample of pediatric mental and behavioral health ED visits over a 14-year period.MethodsWe conducted a cross-sectional analysis of pediatric (6–17 years) mental and behavioral health ED visits using the National Hospital Ambulatory Medical Care Survey, 2006–2019. We describe administration of psychotropic medications by medication type, diagnosis, and over time. Using multivariable survey-weighted logistic regression, we examine associations between medication administration and sociodemographics.ResultsA psychotropic medication was administered in 11.4% of the estimated 11,792,860 pediatric mental and behavioral health ED visits in our sample. Benzodiazepines were administered most frequently (4.9% of visits). Visits with anxiety disorders had the highest frequency of psychotropic medication use (26.7%). Visits by Black non-Hispanic patients had a 60% decreased odds of medication administration compared to visits for White non-Hispanic patients. Visits with public compared to private insurance had a 3.5 times increased odds of psychotropic polypharmacy. The proportion of visits in which a psychotropic medication was administered did not change statistically over time.ConclusionsA psychotropic medication was administered in 1 in 10 pediatric mental and behavioral health ED visits. Use differed by sociodemographics but did not change over time. As more youth seek mental and behavioral health care in the ED, we must better understand appropriate medication use to ensure quality and equitable care.     

Early discharge of preterm infants needing limited special care, followed by domiciliary nursing care

The aim of this study was to evaluate the effect of early discharge, followed by domiciliary nursing care, on infant health and utilization of health services in preterm infants still in need of special care (mainly gavage feeding). In total, 88 infants who were physiologically stable, but in need of further special care such as gavage feeding, were allocated to an early discharge group (EDG = 45 infants) and offered home visits by a nurse backed up by a neonatologist, or to a control group offered standard neonatal care (CG = 43 infants). Infants in the EDG spent 30.6 d (mean) in hospital after birth compared with 46.3 d in the CG (p = 0.003). On average, the domiciliary nurse spent 10.4 h with each family in the EDG, including a median number of 5 home visits, scheduled telephone contact and travelling time. The infants had a mean of 1.7 scheduled visits and 0.4 unscheduled visits to the neonatal ward. The domiciliary nurse received a mean of 0.9 telephone calls from the parents. When the period of domiciliary care in the EDG (post-conceptional age 35.9-38.7 wk) was compared with the corresponding time in hospital in the CG (post-conceptional age 35.6-38.6 wk), no statistical differences were observed in infant health, surgical procedures or medication. However, a reduced incidence of respiratory infections was observed in the EDG (6 versus 16 infants; p = 0.02). Nine infants in the EDG were re-hospitalized. The two groups did not differ in the numbers of rehospitalizations and non-elective contacts with the health services during the first year after discharge. In conclusion, early discharge of preterm infants still requiring special care, followed by domiciliary nursing care, was associated neither with an increased utilization of health services after discharge, nor with infant morbidity after discharge. More information on safety is needed before widespread early discharge can be advocated.     

Health literacy and disease-specific knowledge of caregivers for children with sickle cell disease

This study was conducted to measure the health literacy (HL) and disease-specific knowledge (DSK) of caregivers for children with sickle cell disease (SCD) and relate them to their child's health care utilization. The authors conducted a cross-sectional study of caregiver-child dyads attending an urban pediatric sickle cell clinic. Caregivers were administered the Shortened Test of Functional Health Literacy (S-TOFHLA) and a locally developed DSK questionnaire. Retrospective review of the child's electronic medical record (EMR) was performed to determine annual emergency department (ED) visits and hospitalizations. A total of 142 caregiver-child dyads were recruited for the study. Less than 5% of caregivers had limited HL, with less education (P =.03) and primary language other than English (P =.04) being the only risk factors. Although caregiver HL was not associated with ED visits or hospitalizations, surprisingly DSK was. Caregivers with higher DSK scores had children with higher annual rates of ED utilization (P =.002) and hospitalizations (P =.001), and these children were also more likely to be classified as high ED utilizers (≥4 visits per year; P =.01). Further, caregiver adherence to medication and clinic visits was associated with their child's age (P =.01). Although HL and DSK are both constructs that measure basic health understanding, they differently affect caregivers' ability to navigate and understand the health care system of children with chronic illnesses. This study suggests that the DSK/health care utilization relationship may be a more important measure than HL for programs following children with sickle cell disease and could also have applications in other pediatric chronic diseases.     

Use of asthma guidelines by primary care providers to reduce hospitalizations and emergency department visits in poor, minority, urban children

OBJECTIVES: To determine whether an organized, citywide asthma management program delivered by primary care providers (PCPs) increases adherence to the National Asthma Education and Prevention Program (NAEPP) Asthma Guidelines and whether adherence to the guidelines by PCPs decreases medical services utilization in low-income, minority children. STUDY DESIGN: Analysis of the utilization of medical services for a cohort of 3748 children with asthma who presented for care at one of six primary care urban clinics in Hartford, Connecticut, and who were enrolled in a disease management program (Easy Breathing) between June 1, 1998 and August 31, 2002. RESULTS: Of the 3748 children with physician-confirmed asthma, 48% had persistent disease. Paid claims for inhaled corticosteroids increased 25% ( P <.0001) after enrollment in Easy Breathing. Provider adherence to the NAEPP guidelines for anti-inflammatory therapy increased from 38% to 96%. Easy Breathing children with asthma experienced a 35% decrease in overall hospitalization rates ( P <.006), a 27% decrease in asthma emergency department (ED) visits ( P <.01), and a 19% decrease in outpatient visits ( P <.0001). CONCLUSIONS: An organized, disease management program increased adherence to the NAEPP guidelines for anti-inflammatory use by PCPs in urban clinics. Adherence to this element of the guidelines by PCPs reduced hospitalizations, ED visits, and outpatient visits for children with asthma.     

Intervention strategies for children poorly adherent with asthma medications; one center's experience

Poor adherence to medications and other aspects of the treatment plan is common in pediatric patients with asthma, and is a common reason for inadequate asthma control. In selected patients we have used electronic monitoring of pulmonary function, behavior contracts, home nursing visits, and medical neglect reports in an attempt to improve adherence and asthma control. Improved outcomes were seen with the most aggressive intervention, home nursing, and medical neglect referral, but not with less aggressive measures.     

Potential cost savings of decreased emergency department visits through increased continuity in a pediatric medical home.

PURPOSE: To determine the potential cost savings of decreased emergency department (ED) visits resulting from increased continuity of care provided in a pediatric medical home. METHODS: An economic modeling study comparing the cost of ED visits associated with average continuity of care versus the cost of ED visits associated with a 10% point increase in continuity was performed. This model's premise is that increased continuity will decrease care in the ED. Parameters of the model included average continuity of care and expected use of the ED by pediatric patients as well as the relationship between these two variables. Parameters were estimated from the literature. Average continuity, as measured by the Continuity of Care Index by Bice and Boxerman, was determined to be 40%. Average ED use was estimated to be 0.68 visits/child per year. Continuity of care was stratified into low, medium, and high levels. The Medical University of South Carolina's ED charges were used. An average pediatric practice was estimated to contain 2000 patients. RESULTS: Two hypothetical practices of 2000 patients each were created to represent pediatric medical homes: practice 1 received 40% continuity and practice 2 received 50%. The model's outcome was measured in terms of expected ED charges per practice averted over a 1-year period. Increasing continuity of care by 10% points yielded a decline in expected ED visits from 1362 to 1290 per practice: 19,905 US dollars was saved. CONCLUSION: Continuity of care can yield many benefits, including cost savings from decreased charges associated with less frequent ED use.     

Preventing or accelerating emergency care for children with complex healthcare needs.

OBJECTIVE: A subgroup of children with special health care needs (CSHCN) have chronic and complex medical conditions and frequently attend the emergency department (ED). Some of these ED visits could be prevented through appropriate clinician advice or, if an ED visit is unavoidable, the management time could be decreased. We set out to determine whether an ED-based advice and coordination programme was feasible and could prevent or accelerate ED care for these patients. METHODS, SETTING AND PATIENTS: We identified CSHCN who frequently attended the ED at a large tertiary children's hospital. These patients were enrolled in an ED-based coordination programme, the Accelerated Care through Emergency (ACE) programme providing 24-hour mobile-phone access to experienced ED nurses. We prospectively tracked usage patterns and determined the rate of ED visits after receiving phone advice and the waiting time for patients to be seen in ED. Parental satisfaction and cost of the programme were also assessed. RESULTS: After a pilot phase in 2002, enrollment in the programme increased from 125 in 2003 to 220 patients in 2006. Patients had a broad range of medical conditions. All had two or more and up to 22 medical services involved in their care. 80% of patients used a technical device or implant. Phone calls increased from an initial average of 31 per month in 2003 (0.24 calls per participant) to 66 per month in 2006 (0.3 calls per participant), 60% of which were after hours. The percentage of ED reviews per phone call dropped from an initial 74.2% (95% CI 55.2%-88.1%) in 2003 to 50.0% (95% CI 37.4%-62.5%) in 2006 (p = 0.02). However, decreases in ED visits and admissions as a percentage of enrolled patients and as a percentage of phone calls to ACE staff were not statistically significant. Mean waiting time for enrolled patients remained below 30 minutes. Parent satisfaction with the programme was rated 8.3 on a 0-10 scale (0 meaning poor, 10 meaning excellent). The approximate cost of the programme per child was AU$750 (292 pounds sterling) per year. CONCLUSION: We have developed a coordinated approach towards the provision of healthcare for a group of families with diverse severe chronic medical conditions who frequently present to the ED. Through a comprehensive programme including the development of patient-care plans, care coordination and 24-hour mobile-phone access we were able to enhance families' capacities to manage their children's conditions in the community.     

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.     

Impact of Newborn Follow-up Visit Timing on Subsequent ED Visits and Hospital Readmissions: An Instrumental Variable Analysis

ObjectiveTo determine whether newborn first outpatient visit (FOV) within 3 days of discharge is associated with reduced rates of emergency department (ED) visits and hospital readmissions.MethodsRetrospective cohort analysis was performed of all newborns who were born and had outpatient follow-up within a large academic medical center to determine whether they had ED visits or hospital readmission within 2 weeks after hospital discharge. Multivariable regression using an instrumental variable for timing of FOV was conducted to estimate the relationship between FOV within 3 days of discharge and ED visits and hospital readmissions within 2 weeks of discharge, adjusting for potential confounders. Stratified analyses assessed this relationship in subpopulations with medical or social risk factors.ResultsOf 3282 newborns, 178 (5%) had 1 or more ED visits or hospital readmissions within 2 weeks of hospital discharge. FOV within 3 days was not significantly associated with ED visits and readmissions in the instrumental variable analysis (IVA) (−0.035, P = .11) or the ordinary least squares analysis (OLS) (0.006, P = .52). The difference in coefficients between these analyses, however, suggests that IVA successfully adjusted for some unmeasured bias. In stratified analyses, only newborns born to African American mothers or discharged by family medicine providers demonstrated a significant relationship between FOV within 3 days and reduced odds of ED visits and readmissions.ConclusionsNo significant relationship between outpatient visit timing and ED visits and hospital readmissions was found. Further study is needed to assess the impact of early outpatient visits on other newborn outcomes.     

"Narrowing the Gap": decreasing emergency department use by children enrolled in the Medicaid program by improving access to primary care

OBJECTIVE: To evaluate the effectiveness of increased primary care access created by North Carolina's Medicaid managed care plan, Carolina Access (CA), in reducing unnecessary emergency department (ED) use in Guilford County. METHODS: Emergency department records of pediatric visits before and after the implementation of CA were analyzed. Variables included patient age, International Classification of Diseases, Ninth Revision discharge diagnosis, insurance status, date of visit, time of visit, and ZIP code. Visits were classified as either urgent or nonurgent based on discharge diagnosis. Rates of ED use per 1000 persons were calculated using county population and Medicaid enrollment figures. RESULTS: A total of 54,742 ED visits occurred between January 1, 1995, and December 31, 1997. Thirty-eight percent of these visits were by children (defined as those aged 0-18 years in this study) enrolled in the Medicaid program. After the implementation of CA, monthly ED rates per 1000 children with Medicaid insurance decreased 24% from 33.5 +/- 5.3 to 25.6 +/- 2.3 (P<.001), which translates to 158 fewer visits per month by children enrolled in the Medicaid program. Nonurgent visits among the population enrolled in the Medicaid program decreased from an average monthly rate per 1000 of 17.9 +/- 3.5 to 11.2 +/- 2.5 after the implementation of CA (P<.001), accounting for most of the decrease in total visits. (All data are given as mean +/- SD.) The rates of total and nonurgent visits among the population not enrolled in the Medicaid program increased slightly. CONCLUSIONS: For children with Medicaid insurance, we found a strong temporal relation between decreased visits to the ED and increased access to primary care services, services that were made available by the implementation of North Carolina's Medicaid managed care plan, CA. Specific services that may be responsible for the decreased ED use include the expanded availability of primary care physicians and the use of telephone triage systems. No similar decrease in ED use was seen among the non-Medicaid-insured group. Arch Pediatr Adolesc Med. 2000;154:791-795     

Principles of managing children with asthma in the emergency department

INTRODUCTION

Paediatric asthma exacerbations comprise a significant portion of emergency department (ED) visits and hospitalizations. Recognition of diagnostic symptoms and signs, and timely use of appropriate medications may reduce the need of hospitalizations and the impact of this disease on the lives of children and their families.

OBJECTIVE

To review the pathophysiology of asthma, the current recommendations for conventional medical treatment in the ED, the controversies surrounding adjunct therapies, and the importance of discharge planning and follow-up.

CONCLUSIONS

Paediatric asthma exacerbations may be successfully treated in the ED with the use of appropriate inhaled and systemic medications.     

Associations between housing instability and food insecurity with health care access in low-income children.

OBJECTIVE: Homelessness and hunger are associated with poor health care access among children. Housing instability and food insecurity represent milder and more prevalent forms of homelessness and hunger. The aim of this study was to determine the association between housing instability and food insecurity with children's health care access and acute health care utilization. METHODS: We conducted a cross-sectional analysis of 12,746 children from low-income households included in the 2002 National Survey of America's Families (NSAF). In multivariate models controlling for important covariates, we measured the association between housing instability and food insecurity with 3 health care access measures: 1) no usual source of care, 2) postponed medical care, and 3) postponed medications. We also measured 3 health care utilization measures: 1) not receiving the recommended number of well-child care visits, 2) increased emergency department visits, and 3) hospitalizations. RESULTS: Our analysis showed that 29.5% of low-income children lived in households with housing instability and 39.0% with food insecurity. In multivariate logistic regression models, housing instability was independently associated with postponed medical care, postponed medications, and increased emergency department visits. Food insecurity was independently associated with no usual source of care, postponed medical care, postponed medications, and not receiving the recommended well-child care visits. CONCLUSION: Families that experience housing instability and food insecurity, without necessarily experiencing homelessness or hunger, have compromised ability to receive adequate health care for their children. Policy makers should consider improving programs that decrease housing instability and food insecurity, and clinicians should consider screening for housing instability and food insecurity so as to provide comprehensive care.     

Use of the emergency department by children enrolled in a primary care clinic

Two thousand forty-four emergency department (ED) visits were made during a one-year period by 714 children enrolled in a primary care clinic. Eight hundred one (39.2%) visits were for urgent or emergent conditions, and 579 (28.3%) were for presenting complaints suggestive of urgent or emergent conditions, including 65 based on parental concern. Six hundred sixty-four (32.5%) visits might have been considered medically inappropriate using criteria specifically developed for this study. These criteria were developed as a standard which might be used for future studies on ED use by children. Children without medical assistance and those over 12 months of age were more likely to be consistently appropriate users. Appropriateness of use was not associated with the patient's race, sex, distance of home from the hospital, telephone availability, length of clinic enrollment, type of primary provider, or chronic disease other than asthma. Further, medical assistance recipients were more likely to make three or more inappropriate visits than were the other groups.     

After-hours telephone triage and advice in private and nonprivate pediatric populations

OBJECTIVES: To compare the content of after-hours medical triage and advice calls regarding private practice patients vs nonprivate practice patients and to assess caregiver compliance with advice resulting from these calls. DESIGN: Survey of after-hours medical triage and advice calls during a 2-week period (September 1 through 15, 1996). SETTING: Three private practices (serving approximately 24 000 patients) and 1 urban hospital-based, non-private practice (serving approximately 12 000 patients). SUBJECTS: After-hours medical triage and advice calls from caregivers of patients receiving their primary care in these settings. MAIN OUTCOME MEASURE: Compliance with recommended emergency department (ED) or office visit referrals. RESULTS: A total of 286 calls regarding private practice patients and 377 calls regarding nonprivate practice patients were received (P<.001). Eighty-one calls were referred by the nurse directly to the physician. Fifty-nine private practice patients and 59 nonprivate practice patients were referred to the ED. Caregivers of 94 private practice patients and 132 nonprivate practice patients were given home treatment advice. Appointments to be seen at their primary care source were given for 78 private practice patients and 160 nonprivate practice patients. Non-private practice patients were more likely to be referred for office care (P=.005); private practice patients were more likely to be referred to the ED (P=.01). Compliance with ED referrals was 42% for patients of nonprivate practice and 46% for private practice; for office visit referrals, compliance was 64% for nonprivate practice and 69% private practice patients (P=.71 for compliance with ED referrals and P=.40 for compliance with office referrals). CONCLUSIONS: Compliance with recommended physician encounters was not significantly different (and lower than expected) in both groups of patients. Private practice patients are more likely to be referred to the ED. Calls for nonprivate practice patients are more frequent and these patients are more likely to be referred to their primary care source. This difference may be due to caregivers of patients from nonprivate practices seeking advice for less serious conditions. Physicians should address telephone medicine with caregivers proactively during health maintenance visits.     

Urban emergency department utilization by adolescents

This study describes urban emergency department (ED) utilization and follow-up referral patterns among adolescents. ED visits for 14-19-year-old patients at an urban university hospital with adjacent adult and pediatric emergency departments during specified months in 1993 were retrospectively reviewed. A subgroup (n=150) was randomly selected for detailed chart review. One thousand six hundred and thirty-six adolescents were seen in the ED during the study period. Public assistance (n=763; 47%) and commercial insurance (n=480; 29%) were the most common forms of insurance, followed by self-pay (n=357; 22%). The majority of triage codes for ED visits were nonurgent (n=140; 93%). Twenty-five patients (17%) were not referred for follow-up upon ED discharge. Adolescents on public assistance or without insurance may frequently utilize an urban ED for nonurgent medical problems. A group of patients did not identify a primary care provider at triage and were not referred for follow-up. Defining medical problems for which adolescents utilize the ED may help health professionals to tailor community resources to better serve adolescent health care needs.     

Comparability of acute asthma severity assessments by parents and respiratory therapists

OBJECTIVE: To compare the assessments of parents and respiratory therapists (RTs) of acute asthma severity in children discharged after emergency department (ED) treatment. DESIGN: Prospective cohort study. SETTING: Home care visit within 24 hours of discharge from an urban children's hospital ED. PARTICIPANTS: Children aged 2 to 17 years discharged to home after treatment in the ED (at least 1 inhaled bronchodilator treatment administered) were randomly selected to have a home care visit. MAIN OUTCOME MEASURES: Registered RTs went to the child's home and asked the parent questions about his or her perception of the child's symptoms. The RT performed a clinical assessment including pulse oximetry. RESULTS: Ninety children were selected for home care, and 51 patients (57%) successfully completed the home care visit; 48 (53%) underwent a complete assessment by both raters. There were no differences in demographic features or ED clinical variables between those successfully contacted and those not reached. Of those evaluated, 43 parents (84%) reported their child's asthma was improved, and the rest reported no change. Parents underestimated the degree of wheezing or work of breathing relative to the RT in 3 of 48 patients (6%), but only 1 of these was considered substantial (>1 point discrepancy). Findings were overestimated in 14 (29%) of 48 cases, but only 5 (10%) were substantial. CONCLUSIONS: Parents and RTs provide comparable assessments of acute asthma severity in children within 24 hours of discharge from the ED. Clinically important discrepancies are uncommon, and underestimation of severity by parents is rare.