Preschool children who are frequent attenders in emergency departments: an observational study of associated demographics and clinical characteristics

Blair M, Poots AJ, Lim V, et al. Preschool children who are frequent attenders in emergency departments: an observational study of associated demographics and clinical characteristics. Archives of Disease in Childhood Published Online First: 02 August 2017. doi: 10.1136/archdischild-2016-311952

Background Unscheduled visits to emergency departments (ED) have increased in the UK in recent years. Children who are repeat attenders are relatively understudied.

Aims To describe the sociodemographic and clinical characteristics of preschoolers who attend ED a large District General Hospital.

Method/study design Observational study analysing routinely collected ED operational data. Children attending four or more visits per year were considered as ‘frequent attenders’. Poisson regression was used with demographic details (age, sex, ethnicity, sociodemographic status) to predict number of attendances seen in the year. We further analysed detailed diagnostic characteristics of a random sample of 10% of attendees.

Main findings 10 169 patients visited in the 12-month period with 16 603 attendances. 655 individuals attended on 3335 occasions. 6.4% of this population accounted for 20.1% of total visits. In the 10% sample, there were 304 attendances, and 69 (23%) had an underlying chronic long-standing illness (CLSI). This group were 2.4 times more likely to be admitted as inpatients compared with those without such conditions, median length of stay of 6.2 hours versus 2.5 hours (p=NS).

Conclusions Frequent ED attenders fall broadly into two distinct clinical groups: those who habitually return with self-limiting conditions and those with or without exacerbation of underlying CLSI. Both groups may be amenable to both additional nursing and other forms of community support to enhance self-care and continuity of care. Further research is required to increase our understanding of specific individual family and health system factors that predict repeat attendance in this age group.

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International comparison of emergency hospital use for infants: data linkage cohort study in Canada and England

Harron K, Gilbert R, Cromwell D, et al.   International comparison of emergency hospital use for infants: data linkage cohort study in Canada and England
BMJ Qual Saf Published Online First: 12 June 2017. doi: 10.1136/bmjqs-2016-006253

Abstract
Objectives  To compare emergency hospital use for infants in Ontario (Canada) and England.
Methods We conducted a population-based data linkage study in infants born ≥34 weeks’ gestation between 2010 and 2013 in Ontario (n=253 930) and England (n=1 361 128). Outcomes within 12 months of postnatal discharge were captured in hospital records. The primary outcome was all-cause unplanned admissions. Secondary outcomes included emergency department (ED) visits, any unplanned hospital contact (either ED or admission) and mortality. Multivariable regression was used to evaluate risk factors for infant admission.
Results The percentage of infants with ≥1 unplanned admission was substantially lower in Ontario (7.9% vs 19.6% in England) while the percentage attending ED but not admitted was higher (39.8% vs 29.9% in England). The percentage of infants with any unplanned hospital contact was similar between countries (42.9% in Ontario, 41.6% in England) as was mortality (0.05% in Ontario, 0.06% in England). Infants attending ED were less likely to be admitted in Ontario (7.3% vs 26.2%), but those who were admitted were more likely to stay for ≥1 night (94.0% vs 55.2%). The strongest risk factors for admission were completed weeks of gestation (adjusted OR for 34–36 weeks vs 39+ weeks: 2.44; 95% CI 2.29 to 2.61 in Ontario and 1.66; 95% CI 1.62 to 1.70 in England) and young maternal age.
Conclusions Children attending ED in England were much more likely to be admitted than those in Ontario. The tendency towards more frequent, shorter admissions in England could be due to more pressure to admit within waiting time targets, or less availability of paediatric expertise in ED. Further evaluations should consider where best to focus resources, including in-hospital, primary care and paediatric care in the community.

Full text is available here

Prevalence of non-accidental trauma among children at ACS verified pediatric trauma centers

Child abuse remains a national epidemic that has detrimental effects if unnoticed in the clinical setting | Journal of Trauma and Acute Care Surgery

Background: Extreme cases of child abuse, or non-accidental trauma (NAT), have large financial burdens associated with them due to treatment costs and long-term effects of abuse. Clinicians that have additional training and experience with pediatric trauma are better equipped to detect signs of NAT and have more experience reporting it. This additional training and experience can be measured by using the American College of Surgeons (ACS) Pediatric Trauma Verification. It is hypothesized that ACS verified Pediatric Trauma Centers (vPTCs) have an increased prevalence of NAT due to this additional experience and training when relative to non-ACS vPTCs.

Conclusions: The greater prevalence of NAT at vPTCs likely represents a more accurate measure of NAT among pediatric trauma patients, likely due to more experience and training of clinicians.

Full reference: Bogumil, D.D.A. et al. (2017) Prevalence of non-accidental trauma among children at ACS verified pediatric trauma centers. Journal of Trauma and Acute Care Surgery: Published online: 20 June 2017

 

Ultrasound for children with abdominal trauma

Despite evidence showing that the routine use of sonography in hospital emergency departments can safely improve care for adults when evaluating for possible abdominal trauma injuries, researchers at UC Davis Medical Center could not identify any significant improvements in care for pediatric trauma patients | ScienceDaily

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The findings, which resulted from a randomized clinical study involving 925 children with blunt torso trauma who were evaluated in the emergency department at the medical center, showed no difference in important clinical outcomes. The outcomes assessed were developed for the study mainly based on previous research in injured adults.

The UC Davis team investigated the Focused Assessment with Sonography for Trauma (FAST) to determine whether the use of the FAST examination could safely lead to a decrease in the use of computed tomography (CT) scans for children, and other outcomes. FAST is a bedside ultrasound examination using a portable ultrasound machine. It has not been routinely used in the initial emergency department evaluations of injured children. CT scans represent the “gold standard” in diagnostic imaging for clinicians, including the identification of intra-abdominal injuries, but they also pose a greater radiation risk for children than they do for adults.

The role of nurses’ clinical impression in the first assessment of children at the emergency department

This study explores the diagnostic value and determinants of nurses’ clinical impression for the recognition of children with a serious illness on presentation to the emergency department (ED) | Archives of Disease in Childhood

Main outcome measures: Diagnostic accuracy of nurses’ clinical impression for the prediction of serious illness, defined by intensive care unit (ICU) and hospital admission. Determinants of nurses’ impression that a child appeared ill.

Results: Nurses considered a total of 1279 (20.0%) children appearing ill. Sensitivity of nurses’ clinical impression for the recognition of patients requiring ICU admission was 0.70 (95% CI 0.62 to 0.76) and specificity was 0.81 (95% CI 0.80 to 0.82). Sensitivity for hospital admission was 0.48 (95% CI 0.45 to 0.51) and specificity was 0.88 (95% CI 0.87 to 0.88). When adjusted for age, gender, triage urgency and abnormal vital signs, nurses’ impression remained significantly associated with ICU (OR 4.54; 95% CI 3.09 to 6.66) and hospital admission (OR 4.00; 95% CI 3.40 to 4.69). Ill appearance was positively associated with triage urgency, fever and abnormal vital signs and negatively with self-referral and presentation outside of office hours.

Conclusion: The overall clinical impression of experienced nurses at the ED is on its own, not an accurate predictor of serious illness in children, but provides additional information above some well-established and objective predictors of illness severity.

Full reference: Zachariasse, J.M. et al. (2017)  The role of nurses’ clinical impression in the first assessment of children at the emergency department. Archives of Disease in Childhood. Published Online First: 10 June 2017

Ultrasound for children with broken arms: Accurate, faster, less painful than X-rays

Point-of-Care Ultrasound (POCUS) assessment of distal forearm injuries in children is accurate, timely, and associated with low levels of pain and high caregiver satisfaction | ScienceDaily

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There are many goals when managing children with suspected fractures of the arm. These include being fast and accurate in the diagnosis, not causing more pain and limiting exposure to radiation. Achieving these goals can result in high rates of caregiver satisfaction. Dr. Poonai’s study suggests that POCUS may be a viable alternative to x-ray with respect to diagnostic accuracy, cost effectiveness, pain, caregiver satisfaction, and procedure duration.

Read the full overview via ScienceDaily here

The original research article is available here

 Emergency hospital care for children and young people

What has changed in the past 10 years? | QualityWatch

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Image source: QualityWatch

This short research summary explores how children and young people’s use of emergency care has changed over the past 10 years and seeks to understand what this might mean for care quality.

Emergency care across the NHS in England is under great pressure. The number of people attending Accident & Emergency (A&E) departments is at an all-time high demand for beds is also at record levels and the four-hour A&E target (of seeing 95 per cent of patients arriving at A&E within four hours) has not been met since July 2013.

Discussion of the pressures on emergency care within the NHS tends to focus predominantly on older people. This is understandable – the over 65s account for the majority of emergency bed days in NHS hospitals, stay longer in A&E than the rest of the population and are more likely to be admitted to hospital in an emergency.

However, children and young people – defined as people under the age of 25 – are also frequent users of emergency care, attending A&E more frequently than the adult population. Their healthcare needs can be very different from adults, meaning they often require specialist support, and – like older people – they can be particularly vulnerable and dependent on carers.

Download the full report here