Acceptance of family member presence during pediatric resuscitations in the emergency department: effects of personal experience

OBJECTIVE: Opinions remain polarized on allowing family member presence during pediatric resuscitations (FMP). Reluctance to adopt FMP may stem from preconceived notions on this practice. This study evaluates the effect of prior experience with FMP and on its acceptance by emergency department personnel (EDP). METHODS: EDP from three different EDs were surveyed concerning FMP. Study facilities included an urban teaching community ED with routine FMP (R-ED), a suburban community ED with occasional FMP (O-ED) and an urban university pediatric ED with virtually no FMP (N-ED) during pediatric resuscitations. Survey information included hospital of practice, position in ED, years in practice, opinions on FMP and personal experience with FMP for five clinical scenarios: laceration repair (LAC), intravenous access (IV), lumbar puncture (LP), endotracheal intubation (ETI), cardiopulmonary resuscitation (CPR), and critical resuscitation (CR). Statistical analysis was through chi square and regression analysis. RESULTS: Eighty-five emergency department personnel participated in the survey, 57 (67%) nurses, 22 (25%) physicians, 4 technicians (5%), and 2 nurses aids (2%). There was a significant correlation between a favorable opinion concerning family member presence during LP, ETI, CPR and CR and the type of Emergency Department in which the individual practiced (P<0.002). Regression analysis demonstrated a similar relation between personal experience with LAC, IV, ETI, CR, and CPR and a favorable opinion on FMP during that activity (P<0.03). CONCLUSION: Opinions on FMP are strongly influenced by experience with this practice. Emergency department personnel with prior exposure to family member presence during resuscitations favor this activity. Biases by EDP lacking experience with FMP may limit its introduction into unfamiliar institutions.     

规范儿科急诊预检与分诊

分析儿科急诊预检分诊的国内外现状,阐述急诊预检分诊的目的及正确实施预检分诊在急诊医疗服务中的重要性,提出对儿科急诊预检分诊的建议和设想.     

Delirium in the pediatric emergency department

Clinical presentations in the pediatric emergency department (ED) are frequently complicated by acute changes in mental status consistent with delirium. These patients may be considered management problems because of persistent oppositional and aggressive behavior, or may be depressed because of a flat, anhedonic, or unresponsive appearance. As a consequence of the delirium, their management is complicated by an inability to cooperate or participate in their own care. The subjective experience for the patient is also distressing because they frequently recognize the deterioration in their own behavior and cognitive skills. These patients can be effectively diagnosed in the ED, and appropriate treatment recommended and initiated.     

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.     

Rapid sequence intubation for pediatric emergency airway management

OBJECTIVES: To characterize current practice with respect to pediatric emergency airway management using a multicenter data set. METHODS: A multicenter collaboration was undertaken to gather data prospectively regarding emergency intubation. Analysis of data on adult emergency department (ED) intubations clearly demonstrated that rapid sequence intubation (RSI) was the method used most often. We then conducted an observational study of the prospectively collected database of pediatric ED intubations (EDIs) using the National Emergency Airway Registry Phase One data, gathered in 11 participating EDs over a 16-month time period. A data form completed at the time of EDI enabled analysis of patients' ages, weights, and indications for EDI; personnel; methods employed to facilitate EDI; success rates; and adverse events. Data forms were analyzed regarding the methods of intubation employed, and frequencies, success rates, and adverse event rates among various intubation modalities were compared. RESULTS: Of 1288 EDIs, there were 156 documented pediatric patients. Initial intubation attempts were all oral, including rapid sequence intubation in 81%, without medications (NOM) in 13%, and sedation without neuromuscular blockade (SED) in 6%. Older children and trauma patients were more likely to be intubated with RSI compared to younger children and patients presenting with medical illnesses. Intubation using RSI was more successful on the first attempt (78%) compared with either NOM (47%, < 0.01) or SED (44%, < 0.05), though this finding is likely explainable by the age differences among groups. Intubation was successfully performed by the initial intubator in 85% of RSI, 75% of NOM, and 89% of SED attempts ( = NS for both comparisons vs RSI). Overall, successful intubation occurred in 99% of RSI and 97% of non-RSI intubation attempts ( = NS). Only one of 156 patients required surgical airway management. True complications occurred in 1%, 5%, and 0% of RSI, NOM, and SED attempts, respectively ( = NS for both comparisons vs RSI). The majority of initial intubation attempts were by emergency medicine residents (59%), pediatric emergency medicine fellows (17%), and pediatrics residents (10%). These groups were 77%, 77%, and 50% successful, respectively, on the first laryngoscopy attempt, and 89%, 89%, and 69% successful overall. CONCLUSIONS: A large, prospective, multicenter observational study of pediatric EDIs was conducted at university-affiliated EDs. RSI is the method of choice for the majority of pediatric emergency intubations; it is associated with a high success rate and a low rate of serious adverse events. Pediatric intubation as practiced in academic EDs, with most initial attempts by emergency and pediatrics residents and fellows under attending physician supervision, is safe and highly successful.     

Safety and efficacy of rocuronium for controlled intubation with paralytics in the pediatric emergency department

BACKGROUND: Controlled intubation in the pediatric emergency department (ED) requires a paralytic agent that is safe, efficacious, and of rapid onset. The safety of succinylcholine has been challenged, leading some clinicians to use vecuronium as an alternative. Rocuronium's onset is similar to that of succinylcholine. OBJECTIVE: To evaluate the safety and efficacy of rocuronium for controlled intubation with paralysis (CIP) in the pediatric ED. METHODS: A retrospective, observational study reviewed the records of patients less than 15 years of age, who received controlled intubation with paralytics at two Dallas EDs. The patients received either vecuronium or rocuronium. RESULTS: The study included 84 patients (vecuronium 19, rocuronium 65). Complications were similar between the two groups. Rocuronium had a shorter time from administration to intubation when compared to vecuronium (P < 0.05). CONCLUSION: Rocuronium is as safe and efficacious as vecuronium for CIP in the pediatric ED.     

Regionalization of pediatric emergency care in Korea

In order to care for an ill or injured child, it is crucial that every emergency department (ED) has a minimum set of personnel and resources because the majority of children are brought to the geographically nearest ED. In addition to adequate preparation for basic pediatric emergency care, a comprehensive, specialized healthcare system should be in place for a critically-ill or injured victim. Regionalization of healthcare means a system providing high-quality and cost-effective care for victims who present with alow frequency, but critical condition, such as multiple trauma or cardiac arrest. Within the pediatric field, neonatal intensive care and pediatric trauma care are good examples of regionalization. For successful regionalized pediatric emergency care, all aspects of a pediatric emergency system, from pre-hospital field to hospital care, should be categorized and coordinated. Efforts to set up the pediatric emergency care regionalization program based on a nationwide healthcare system are urgently needed in Korea.     

Effect of educational program on compliance with glove use in a pediatric emergency department.

OBJECTIVE--To investigate the effect of an educational program on compliance with glove use in a pediatric emergency department. DESIGN--Without their knowledge, participants were observed for routine use of gloves during vascular access procedures before and after an educational program. Participants with up to 3 years' vascular access experience were defined as less experienced and those with 4 or more years' experience were defined as more experienced. Their success rates performing vascular access procedures with and without wearing gloves were also monitored. SETTING--Inner-city pediatric hospital emergency department. PARTICIPANTS--Twenty-three emergency department registered nurses. INTERVENTIONS--A 30-minute lecture with slides, written materials, and posters addressing the reasons and need for universal precautions, and recommended methods of barrier precautions to prevent skin and mucous membrane exposure when handling sharp instruments. MEASUREMENTS/MAIN RESULTS--For the less experienced registered nurses, the compliance rate before the educational program was 70% and remained at about 93% afterward. For the more experienced registered nurses, the compliance rate before the program was only 15%. After the program, this compliance rate rose to 93%, but declined to only 50% by the fifth month. The registered nurses' success rate on the first attempt at vascular access while wearing gloves was 75% compared with 70% without gloves. CONCLUSION--Educational programs can result in a clinically significant increase in glove use by pediatric emergency department registered nurses. Long-term improvement was less pronounced for the group of more experienced registered nurses. We also observed that glove use does not appear to interfere with the proficient performance of vascular access procedures.     

Strategies to improve flow in the pediatric emergency department

As emergency departments (EDs) experience overcrowding, there is ever-growing pressure to improve patient flow. We present a review of strategies to increase efficiency of patient inflow, throughput, and output in the ED, with an emphasis on approaches that are under greater control of the ED itself and therefore more amenable to implementation without major institutional changes.     

Association of emergency department care factors with admission and discharge decisions for pediatric patients

OBJECTIVE: We evaluated overutilization or underutilization of inpatient resources to measure the emergency department (ED) decision-making process and its association with the following care factors: annual pediatric volume, presence or absence of a pediatric emergency medicine specialist; and presence or absence of ED residents. STUDY DESIGN: Block random selection, using the three care factors, of 16 hospitals with pediatric intensive care units. The Pediatric Risk of Admission (PRISA II) Score was used to measure illness severity. Decision-making was evaluated for admissions (Admission Index: observed minus predicted admissions) and returns (Return Index: observed minus predicted 72-hour returns). The Combined Index was a weighted average of the Admission and Return Indexes. RESULTS: There were 11,664 patients enrolled. Residents but not volume or pediatric emergency medicine specialists were associated with the decision-making performance indexes in multivariable analysis (no residents versus residents: Admission Index: 2.5 of 1000 patients versus 34.8 of 1000, P = .082; Return Index: -3.0 of 1000 versus 33.6 of 1000, P = .039; Combined Index: 1.9 of 1000 versus 35.5 of 1000, P = .024. CONCLUSIONS: There is significant variability in ED decision-making for children. Residents but not volume or presence of a pediatric emergency medicine specialist are associated with increased differences in admission decisions. The process by which these differences occur was not investigated.     

Primary care and emergency department decision making.

OBJECTIVE: To determine the effect of primary care status on decision making in the pediatric emergency department (ED). SETTING: Urban tertiary care children's hospital. DESIGN: Examining physicians prospectively completed questionnaires describing the presence of and their familiarity with patients' primary care providers (PCPs), as well as several relevant clinical factors. PATIENTS: We prospectively surveyed care for patients with triage temperature of 38.5 degrees C or higher or symptoms of gastroenteritis between August 1, 1999, and February 15, 2000. OUTCOME MEASURES: Intravenous fluid use, hospital admission status, rates of diagnostic testing and interventions, mean total costs, and length of ED stay. RESULTS: Among 1166 nonreferred patients, no PCP was identified for 164 patients and PCPs for 1002. The groups did not differ on ethnicity, mean age-adjusted vital signs, triage category, initial appearance, patient care setting (main ED or urgent care clinic), time of day, day of week, certainty of diagnosis, or perceived importance of follow-up. Mean unadjusted direct hospital costs for diagnostic testing were significantly higher for the group without PCPs, $23 vs $16. In regression models controlling for age, ethnicity, insurance status, patient care setting, ED attending physician, temperature, and initial appearance, the absence of a PCP was associated with an increased likelihood of diagnostic testing. Compared with a subset of the cohort with PCPs who were familiar to the treating physicians, the group without PCPs also had a significantly higher rate of intravenous fluid administration. CONCLUSION: In this patient population, ED physicians may vary their assessment and management decisions based on primary care status.     

Ability of hospitals to care for pediatric emergency patients.

CONTEXT: The needs of children in emergency situations differ from those of adults and require special attention, yet there has been no study of the ability of U.S. hospitals to care for emergently or critically ill children. OBJECTIVE: To estimate the distribution of pediatric services available at U.S. hospitals with emergency departments (EDs). DESIGN: Self-report survey of 101 hospital EDs. PARTICIPANTS: Stratified probability sample of all U.S. hospitals operating EDs. RESULTS: The majority of hospitals that usually admit pediatric patients do not have separate pediatric facilities. Hospitals without a pediatric department, ward, or trauma service usually transfer critically injured pediatric trauma patients; however, nearly 10% of hospitals without pediatric intensive care facilities admit critically injured children to their own facilities. Likewise, 7% of hospitals routinely admit pediatric patients known to require intensive care to their adult intensive care units rather than transferring the patient to a facility with pediatric intensive care facilities. Few hospitals have protocols for obtaining pediatric consultation on pediatric emergencies. Appropriately sized equipment for successful care of infants and children in an emergency situation was more likely to be missing than adult-sized equipment, and significant numbers of hospitals did not have adequate equipment to care for newborn emergencies. CONCLUSION: Emergent and critical care of infants and children may not be well integrated and regionalized within our health care system, suggesting that there is room for improvement in the quality of care for children encountering emergent illness and trauma.     

Children and adolescents with acute alcohol intoxication/self-poisoning presenting to the emergency department

OBJECTIVE: To describe the presentations, characteristics, and follow-up care of children and adolescents aged 10 to 18 years who present to emergency departments (EDs) with acute alcohol intoxication/self-poisoning. DESIGN: Retrospective medical record review. SETTING: Five EDs in Western Sydney, Australia. PARTICIPANTS: Patients aged 10 to 18 years who presented to EDs with acute alcohol intoxication/self-poisoning between January 1, 1996, and December 31, 2000. MAIN OUTCOME MEASURES: Frequency of presentations; presentation characteristics; psychosocial characteristics; and presence or absence of follow-up. RESULTS: Two hundred twelve children and adolescents presented to EDs 216 times. Of the 212 patients, 49 (23%) were 14 years or younger, and the youngest was aged 10 years. The majority (82%) came after hours and were brought in by emergency services (77%). In 13% of presentations, verbal and/or physical aggression was present, and a threat of self-harm was present in 2% of cases. A mental health worker was consulted about the child or adolescent in only 6% of presentations. Most children and adolescents (85%) were discharged from the ED. Of concern, in 56% of presentations, a follow-up plan was not recorded. There was documentation of mental health follow-up in only 14% of presentations and follow-up from drug and alcohol services in only 1%. Forensic history, school functioning, and a history of past mental health problems were not documented in more than 60% of the medical records examined. CONCLUSIONS: When children or adolescents present to an ED with acute alcohol intoxication/self-poisoning, their risk factors for psychosocial dysfunction appear to be inadequately assessed, documented, and followed up. Clear guidelines for assessment and referral pathways must be established in EDs.     

Validity of the computerized version of the pediatric triage system CLARIPED for emergency care

ObjectiveTo evaluate the validity of the computerized version of the pediatric triage system CLARIPED.MethodsProspective, observational study in a tertiary emergency department (ED) from Jan-2018 to Jan-2019. A convenience sample of patients aged 0-18 years who had computerized triage and outcome variables registered. Construct validity was assessed through the association between urgency levels and patient outcomes. Sensitivity, specificity, positive and negative predictive values (PPV and NPV), undertriage, and overtriage rates were assessed.Results19,122 of 38,321 visits were analyzed. The urgency levels were: RED (emergency) 0.02%, ORANGE (high urgency) 3.21%, YELLOW (urgency) 35.69%, GREEN (low urgency) 58.46%, and BLUE (no urgency) 2.62%. The following outcomes increased according to the increase in the level of urgency: hospital admission (0.4%, 0.6%, 3.1%, 11.9% and 25%), stay in the ED observation room (2.8%, 4.7%, 15.9%, 40.4%, 50%), ≥ 2 diagnostic or therapeutic resources (7.8%, 16.5%, 33.7%, 60.6%, 75%), and ED length of stay in minutes (18, 24, 67, 120, 260). The odds of using ≥ 2 resources or being hospitalized were significantly greater in the most urgent patients (Red, Orange, and Yellow) compared to the least urgent (Green and Blue): OR 7.88 (95%CI: 5.35-11.6) and OR 2.85 (95%CI: 2.63-3.09), respectively. The sensitivity to identify urgency was 0.82 (95%CI: 0.77-0.85); specificity, 0.62 (95%CI: 0.61-0.6; NPV, 0.99 (95%CI: 0.99-1.00); overtriage rate, 4.28% and undertriage, 18.41%.ConclusionThe computerized version of CLARIPED is a valid and safe pediatric triage system, with a significant correlation with clinical outcomes, good sensitivity, and low undertriage rate.     

A pediatric emergency department follow-up system: completing the cycle of care.

BACKGROUND: Prior to 1993, the follow-up program for our pediatric emergency department (ED) was the responsibility of the rotating senior pediatric resident. There were inherent problems with this system, as a consequence of inconsistent personnel. The residents' revolving schedules and the fact that they were accountable to other clinical areas decreased their availability for follow-up. Also, it was difficult for the clerical staff to identify the person responsible for answering parent calls. The medical director of the ED made the decision to turn the core responsibility for the follow-up program to the nurse practitioners in addition to their direct care provider role. The nurse practitioner group is a consistent member of the treatment team who has the critical thinking skills necessary to handle the majority of issues that require follow-up. The emergency attending physicians are available for consultation whenever questions arise. OBJECTIVE: Review of current follow-up program of a pediatric ED and its impact on patient care, patient/parent satisfaction, and communication with community providers and specialists. METHOD: A retrospective review of the evolution of the multi-faceted follow-up of patients from an urban pediatric ED. RESULTS: Antidotal evidence suggests that a comprehensive follow-up program increases patient satisfaction, improves communication between the ED, primary care providers, and specialists. It also decreases the workload of the attending emergency physicians, allowing them more time to focus on acute issues. In addition, the follow-up program for ED patients can decrease the medical /legal risks associated with reporting of delayed laboratory results. CONCLUSION: The next step in further reviewing this program is the development of a satisfaction questionnaire for patient/ families and community providers to quantify their level of satisfaction with the program. A retrospective chart review of the patients who received a follow-up phone call after discharge, and the return visit rate would be another avenue to pursue to validate our antidotal information.     

一种5级儿科急诊分诊有效性及可靠性分析

目的制定急诊儿科分诊标准并检验该标准在判断急诊儿科患者就诊时病情严重程度分类上的有效性及可靠性。方法按照美国心脏协会、美国儿科学会《儿科高级生命支持》的评估方法,结合我院实际情况制定儿科急诊分诊标准;收集应用该标准前后各1年时间内的分诊数据,统计分析所得资料。结果在应用该分诊标准前后,急诊患儿家属对就诊次序的平均满意度分别为（81．28±3．97）％及（94．13±4．62）％,差异有统计学意义（P〈0．01）;候诊期间病情加重的病例数分别占1．83％（628／34275）及0．04％（16／36187）,差异有统计学意义（P〈0．01）;急诊入院患儿平均候诊时间分别为（12．71±2．32）min及（3．34±1．95）min,差异有统计学意义（P〈0．01）;急诊患儿病情严重程度误判率分别为3．78％（1296／34275）及0．57％（205／36187）,差异有统计学意义（P〈0．05）。结论5级分诊标准适合儿科急诊分诊工作,客观简便,能迅速分检急诊儿科的危重病例,有利于急诊分诊效果的持续改进,合理使用急诊医疗资源,缓解诊室拥挤。     

Effect of a pediatric trauma response team on emergency department treatment time and mortality of pediatric trauma victims

OBJECTIVE: Delay in the provision of definitive care for critically injured children may adversely effect outcome. We sought to speed care in the emergency department (ED) for trauma victims by organizing a formal trauma response system. DESIGN: A case-control study of severely injured children, comparing those who received treatment before and after the creation of a formal trauma response team. SETTING: A tertiary pediatric referral hospital that is a locally designated pediatric trauma center, and also receives trauma victims from a geographically large area of the Western United States. SUBJECTS: Pediatric trauma victims identified as critically injured (designated as "trauma one") and treated by a hospital trauma response team during the first year of its existence. Control patients were matched with subjects by probability of survival scores, and were chosen from pediatric trauma victims treated at the same hospital during the year preceding the creation of the trauma team. INTERVENTIONS: A trauma response team was organized to respond to pediatric trauma victims seen in the ED. The decision to activate the trauma team (designation of patient as "trauma one") is made by the pediatric emergency medicine (PEM) physician before patient arrival in the ED, based on data received from prehospital care providers. Activation results in the notification and immediate travel to the ED of a pediatric surgeon, neurosurgeon, emergency physician, intensivist, pharmacist, radiology technician, phlebotomist, and intensive care unit nurse, and mobilization of an operating room team. Most trauma one patients arrived by helicopter directly from accident scenes. OUTCOME MEASURES: Data recorded included identifying information, diagnosis, time to head computerized tomography, time required for ED treatment, admission Revised Trauma Score, discharge Injury Severity Score, surgical procedures performed, and mortality outcome. Trauma Injury Severity Score methodology was used to calculate the probability of survival and mortality compared with the reference patients of the Major Trauma Outcome Study, by calculation of z score. RESULTS: Patients treated in the ED after trauma team initiation had statistically shorter times from arrival to computerized tomography scanning (27 +/- 2 vs 21 +/- 4 minutes), operating room (63 +/- 16 vs 623 +/- 27 minutes) and total time in the ED (85 +/- 8 vs 821 +/- 9 minutes). Calculation of z score showed that survival for the control group was not different from the reference population (z = -0.8068), although survival for trauma-one patients was significantly better than the reference population (z = 2.102). CONCLUSION: Before creation of the trauma team, relevant specialists were individually called to the ED for patient evaluation. When a formal trauma response team was organized, time required for ED treatment of severe trauma was decreased, and survival was better than predicted compared with the reference Major Trauma Outcome Study population.     

Violence prevention in the emergency department: clinician attitudes and limitations

OBJECTIVE: To assess emergency department (ED) clinicians' attitudes and behaviors regarding identification, assessment, and intervention for youth at risk for violence in the ED. DESIGN: Anonymous, cross-sectional written questionnaire. SETTING: The EDs of 3 urban hospitals. SUBJECTS: Emergency medicine residents and faculty, pediatric residents, pediatric emergency medicine fellows and faculty, and ED nurses. RESULTS: A total of 184 (88%) of 208 clinicians completed the questionnaire. Only 15% correctly recognized the lack of existing protocols for addressing youth violence. Clinicians reported being most active in identification of at-risk youth (93% asking context of injury and 82% determining relationships of victim and perpetrator), with pediatricians being more active than general ED clinicians (87% vs 68%; P<.01). Clinicians less often reported performing assessments or referrals of at-risk youth. Nurses and physicians were no different in their reported identification, assessment, or referral behaviors. Barriers identified include concern over upsetting family members, lack of time or skills, and concern for personal safety. Additional clinician training, information about community resources, and specially trained on-site staff were noted by respondents as potential solutions. CONCLUSIONS: Emergency department clinicians recognize the need for evaluation of youth at risk for violence. They are able to identify violently injured youth, but less often perform risk assessment to guide patients to appropriate follow-up resources. Further investigation should address clinician barriers to the complete care of violently injured youth in the ED.     

Pediatric Asthma in the Community Emergency Department: Room for Improvement and Aligned Incentives

Asthma is a common reason for emergency department (ED) visits in children. Over 80% of children who visit an ED go to a general, not a pediatric-specific, ED. The treatment children with asthma receive in general EDs is not as compliant with national guidelines as is treatment in pediatric-specific centers. Several studies document improvements in pediatric asthma care through quality improvement initiatives, but few address the emergency care of pediatric asthma in the community setting. National programs such as Pathways for Improving Pediatric Asthma and Translating Emergency Knowledge for Kids provide resources to community EDs for improving pediatric asthma care. More research is needed to determine if programs such as these, as well as partnerships at the local level, can have a positive impact on the emergency care of pediatric asthma. It is essential that we bridge the gaps in care between community and pediatric-specific EDs to improve the quality of emergency care for the over 7 million children in the US with asthma.