Quality of Care of Children in the Emergency Department: Association with Hospital Setting and Physician Training

Department of Pediatrics, University of California Davis, Sacramento, CA, USA.
The Journal of pediatrics (Impact Factor: 3.74). 08/2008; 153(6):783-9. DOI: 10.1016/j.jpeds.2008.05.025
Source: PubMed

ABSTRACT To investigate differences in the quality of emergency care for children related to differences in hospital setting, physician training, and demographic factors.
This was a retrospective cohort study of a consecutive sample of children presenting with high-acuity illnesses or injuries at 4 rural non-children's hospitals (RNCHs) and 1 academic urban children's hospital (UCH). Two of 4 study physicians independently rated quality of care using a validated implicit review instrument. Hierarchical modeling was used to estimate quality of care (scored from 5 to 35) across hospital settings and by physician training.
A total of 304 patients presenting to the RNCHs and the UCH were studied. Quality was lower (difference = -3.23; 95% confidence interval [CI] = -4.48 to -1.98) at the RNCHs compared with the UCH. Pediatric emergency medicine (PEM) physicians provided better care than family medicine (FM) physicians and those in the "other" category (difference = -3.34, 95% CI = -5.40 to -1.27 and -3.12, 95% CI = -5.25 to -0.99, respectively). Quality of care did not differ significantly between PEM and general emergency medicine (GEM) physicians in general, or between GEM and PEM physicians at the UCH; however, GEM physicians at the RNCHs provided care of lesser quality than PEM physicians at the UCH (difference = -2.75; 95% CI = -5.40 to -0.05). Older children received better care.
The quality of care provided to children is associated with age, hospital setting, and physician training.


Available from: Stacey Cole, Apr 17, 2015
  • [Show abstract] [Hide abstract]
    ABSTRACT: Introduction: Suboptimal care is frequent in the management of severe bacterial infection. We aimed to evaluate the consequences of suboptimal care in the early management of severe bacterial infection in children and study the determinants. Methods: A previously reported population-based confidential enquiry included all children (3 months- 16 years) who died of severe bacterial infection in a French area during a 7-year period. Here, we compared the optimality of the management of these cases to that of pediatric patients who survived a severe bacterial infection during the same period for 6 types of care: seeking medical care by parents, evaluation of sepsis signs and detection of severe disease by a physician, timing and dosage of antibiotic therapy, and timing and dosage of saline bolus. Two independent experts blinded to outcome and final diagnosis evaluated the optimality of these care types. The effect of suboptimal care on survival was analyzed by a logistic regression adjusted on confounding factors identified by a causal diagram. Determinants of suboptimal care were analyzed by multivariate multilevel logistic regression. Results: Suboptimal care was significantly more frequent during early management of the 21 children who died as compared with the 93 survivors: 24% vs 13% (p = 0.003). The most frequent suboptimal care types were delay to seek medical care (20%), under-evaluation of severity by the physician (20%) and delayed antibiotic therapy (24%). Young age (under 1 year) was independently associated with higher risk of suboptimal care, whereas being under the care of a paediatric emergency specialist or a mobile medical unit as compared with a general practitioner was associated with reduced risk. Conclusions: Suboptimal care in the early management of severe bacterial infection had a global independent negative effect on survival. Suboptimal care may be avoided by better training of primary care physicians in the specifics of pediatric medicine.
    PLoS ONE 09/2014; 9(9):e107286. DOI:10.1371/journal.pone.0107286 · 3.53 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Background. The primary objective of this study was to compare management practices of general emergency physicians (GEMPs) and pediatric emergency medicine physicians (PEMPs) for well-appearing young febrile children. Methods. We retrospectively reviewed the charts of well-appearing febrile children aged 3–36 months who presented to a large urban children's hospital (PED), staffed by PEMPs, or a large urban general emergency department (GED), staffed by GEMPs. Demographics, immunization status, laboratory tests ordered, antibiotic usage, and final diagnoses were collected. Results. 224 cases from the PED and 237 cases from the GED were reviewed. Children seen by PEMPs had significantly less CXRs (23 (10.3%) versus 51 (21.5%), P = 0.001) and more rapid viral testing done (102 (45%) versus 40 (17%), P < 0.0001). A diagnosis of a viral infection was more common in the PED, while a diagnosis of bacterial infection (including otitis media) was more common in the GED. More GED patients were prescribed antibiotics (41% versus 27%, P = 0.002), while more PED patients were treated with oseltamivir (6.7% versus 0.4%, P < 0.001). Conclusions. Our findings identify important differences in the care of the young, well-appearing febrile child by PEMPs and GEMPs and highlight the need for standardization of care.
    International Journal of Emergency Medicine 06/2014; 2014:702053. DOI:10.1155/2014/702053
  • [Show abstract] [Hide abstract]
    ABSTRACT: Variation exists between the qualities of emergency department (ED) care provided to urban versus rural pediatric patients. We implemented a pediatric simulation program in the Critical Access Hospital (CAH) ED setting and evaluated whether this training would increase provider comfort with seriously ill children.
    Pediatric Emergency Care 05/2014; DOI:10.1097/PEC.0000000000000146 · 0.92 Impact Factor