Arpi Bekmezian

University of California, San Francisco, San Francisco, California, United States

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Publications (9)13.16 Total impact

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    ABSTRACT: This study aimed to identify factors associated with delayed or omission of indicated steroids for children seen in the emergency department (ED) for moderate-to-severe asthma exacerbation. This was a retrospective study of pediatric (age ≤ 21 years) patients treated in a general academic ED from January 2006 to September 2011 with a primary diagnosis of asthma (International Classification of Diseases, Ninth Revision code 493.xx) and moderate-to-severe exacerbations. A moderate-to-severe exacerbation was defined as requiring 2 or more (or continuous) bronchodilators. We determined the proportion of visits in which steroids were inappropriately omitted or delayed (>1 hour from arrival). Multivariable logistic regression models were used to identify patient, physician, and system factors associated with delayed or omitted steroids. Of 1333 pediatric asthma ED visits, 817 were for moderate-to-severe exacerbation; 645 (79%) received steroids. Patients younger than 6 years (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.19-4.24), requiring more bronchodilators (OR, 2.82; 95% CI, 2.10-3.79), initially hypoxic (OR, 2.78; 95% CI, 1.33-5.83), or tachypneic (OR, 1.52; 95% CI, 1.05-2.20) were more likely to receive steroids. Median time to steroid administration was 108 minutes (interquartile range, 65-164 minutes). Steroid administration was delayed in 502 visits (78%). Patients with hypoxia (OR, 1.91; 95% CI, 1.11-3.27) or tachypnea (OR, 1.82; 95% CI, 1.17-2.84) were more likely to receive steroids 1 hour or less of arrival, whereas children younger than 2 years (OR, 0.16; 95% CI, 0.07-0.35) and those arriving during periods of higher ED volume (OR, 0.79; 95% CI, 0.67-0.94) were less likely to receive timely steroids. In this ED, steroids were underprescribed and frequently delayed for pediatric ED patients with moderate-to-severe asthma exacerbation. Greater ED volume and younger age are associated with delays. Interventions are needed to expedite steroid administration, improving adherence to National Institutes of Health asthma guidelines.
    Pediatric emergency care 09/2013; · 0.92 Impact Factor
  • Arpi Bekmezian, Paul J Chung
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    ABSTRACT: This study aimed to assess the relationship between boarding of admitted children in the emergency department (ED) and cost, inpatient length of stay (LOS), mortality, and readmission. This was a retrospective study of 1,792 pediatric inpatients admitted through the ED and discharged from the hospital between February 20, 2007 and June 30, 2008 at a major teaching hospital with an annual ED volume of 40,000 adult and pediatric patients.The main predictor variable was boarding time (time from admission decision to departure for an inpatient bed, in hours). Covariates were patient age, payer group, times of ED and inpatient bed arrival, ED triage acuity, type of inpatient service, intensive care unit admission, surgery, and severity of inpatient illness. The main outcome measures, cost (dollars) and inpatient LOS (hours), were log-transformed and analyzed using linear regressions. Secondary outcomes, mortality and readmission to the hospital within 72 hours of discharge, were analyzed using logistic regression. Mean ED LOS for admitted patients was 9.0 hours. Mean boarding time was 5.1 hours. Mean cost and inpatient LOS were $9893 and 147 hours, respectively. In general, boarding time was associated with cost (P < 0.001) and inpatient LOS (P = 0.01) but not with mortality or readmission. Longer boarding times were associated with greater inpatient LOS especially among patients triaged as low acuity (P = 0.008). In addition, longer boarding times were associated with greater probability of being readmitted among patients on surgical services (P = 0.01). Among low-acuity and surgical patients, longer boarding times were associated with longer inpatient LOS and more readmissions, respectively.
    Pediatric emergency care 02/2012; 28(3):236-42. · 0.92 Impact Factor
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    ABSTRACT: To estimate the prevalence of and to identify factors associated with prolonged emergency department length-of-stay (ED-LOS) for admitted children. Data were from the 2001-2006 National Hospital Ambulatory Medical Care Survey. The primary outcome was prolonged ED-LOS (defined as total ED time >8 hours) among admitted children. Predictor variables included patient-level (eg, demographics including race/ethnicity, triage score, diagnosis, and admission to inpatient bed vs intensive care unit), physician-level (intern/resident vs attending physician), and system-level (eg, region, metropolitan area, ED and hospital type, time and season, and diagnostic and therapeutic procedures) factors. Multivariable logistic regression was performed to identify independent predictors of prolonged ED-LOS. Median ED-LOS for admitted children was 3.7 hours. Thirteen percent of pediatric patients admitted from the ED experienced prolonged ED-LOS. Factors associated with prolonged ED-LOS for admitted children were Hispanic ethnicity (odds ratio [OR], 1.76; 95% confidence interval [95% CI], 1.10-2.81), ED arrival between midnight and 8 a.m. (OR, 2.80; 95% CI, 1.87-4.20), winter season (January-March: OR, 1.81; 95% CI, 1.20-2.74), computed tomography scan or magnetic resonance imaging (OR, 1.65; 95% CI, 1.05-2.58), and intravenous fluids or medications (OR, 1.81; 95% CI, 1.10-2.97). Children requiring ICU admissions (OR, 0.29; 95% CI, 0.11-0.77) or receiving pulse oximetry in the ED (OR, 0.52; 95% CI, 0.34-0.81) had a lower risk of experiencing prolonged ED-LOS. We found that prolonged ED-LOS occurs frequently for admitted pediatric patients and is associated with Hispanic ethnicity, presentation during winter season, and early morning arrival. Potential strategies to reduce ED-LOS include improved availability of interpreter services and enhanced staffing and additional inpatient bed availability during winter season and overnight hours.
    Pediatric emergency care 02/2011; 27(2):110-5. · 0.92 Impact Factor
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    ABSTRACT: To determine whether systemic corticosteroids are under-prescribed (as measured by current NIH treatment guidelines) for children in the United States seen in the emergency department (ED) for acute asthma, and to identify factors associated with prescribing systemic corticosteroids. We used data from the 2001-2007 National Hospital Ambulatory Medical Care Survey. The study population was children ≤ 18 years old in the ED with a primary diagnosis of asthma (ICD-9-CM code 493.xx) who received bronchodilator(s). The primary outcome was receipt of a systemic corticosteroid in the ED. Independent variables included patient-level (e.g., demographics, insurance, fever, admission), physician-level (provider type, ancillary medications and tests ordered), and system-level factors (e.g., ED type, geographic location, time of day, season, year). We used multivariable logistic regression techniques to identify factors associated with systemic corticosteroid treatment. Systemic corticosteroids were prescribed at only 63% of pediatric acute asthma visits to EDs. Over the study period, there was a trend toward increasing systemic corticosteroid use (p for trend = .05). After adjusting for potential confounders, patients were more likely to receive systemic corticosteroids when treated in pediatric EDs than in general EDs (OR = 2.45; 95% CI: 1.26-4.77). Systemic corticosteroids are under-prescribed for children who present to EDs with acute asthma exacerbations. Pediatric EDs are more likely than general EDs to treat asthma exacerbations with systemic corticosteroids. Differences in the process of care in pediatric ED settings (compared to general EDs) may increase the likelihood of adherence to NIH treatment guidelines.
    Journal of Asthma 02/2011; 48(1):69-74. · 1.85 Impact Factor
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    Arpi Bekmezian, Jorge Vargas, Paul Krogstad
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    ABSTRACT: A six-week-old boy presented to the emergency department with worsening jaundice. His medical history included congenital diaphragmatic hernia repaired shortly after birth. Significant jaundice, unresponsive to phototherapy, was noted on the eighth day of life. His total bilirubin level decreased when he was advanced to full oral feeds. However, on the 23rd day of life, the patient's conjugated bilirubin level had tripled. This was attributed to total parenteral nutrition, and the patient was discharged home. Over the next month, his jaundice worsened. The patient was readmitted and ultimately diagnosed with cytomegalovirus (CMV) hepatitis. After treatment with ganciclovir, his hepatitis completely resolved. CMV infection is a common cause of neonatal hepatitis and congenital malformation. Prolonged neonatal jaundice that does not improve with transitioning from total parenteral nutrition to oral feeds warrants further evaluation. Simple laboratory investigation can avoid unnecessary and potentially harmful medical and surgical interventions. Early treatment of neonatal CMV infection reduces the risk of long-term neurological and hepatic complications.
    Paediatrics & child health 07/2009; 14(6):389-92. · 1.03 Impact Factor
  • Pediatrics in Review 02/2009; 30(1):15-21. · 0.82 Impact Factor
  • Arpi Bekmezian, Paul J Chung, Shahram Yazdani
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    ABSTRACT: Few studies exist on the ability of standardized preprinted order forms to improve patient care. To examine resident-perceived effects of introducing a pediatric admission order set (PAOS) on the quality of inpatient care. Cross-sectional study. University of California, Los Angeles (UCLA) Children's Hospital, a nonprofit, tertiary-care teaching hospital and major referral center with approximately 3,000 admissions per year. A total of 97 pediatric residents (PL-1, n=34; PL-2, n=33; and PL-3, n=30) who did the vast majority of the inpatient admissions. Residents were asked to rate the PAOS overall and with respect to 9 specific dimensions using a 5-point Likert scale. Overall, 89% of respondents approved of the PAOS, 58% reported using it >or= 90% of the time, and all said that they would recommend it to their colleagues. Eighty-four percent thought that it improved inpatient care, and 75% thought that medical errors were reduced. Eighty-eight percent reported that the PAOS saved time; 93% said it was convenient; and most reported less need for clarification with secretaries (81%) and nurses (82%). In multivariate regression analyses, the only predictor of overall rating was whether the PAOS improved inpatient care (P=0.04). Improved patient care, meanwhile, was predicted by whether the PAOS was comprehensive (P=0.01), reduced medical errors (P=0.01), and required less clarification with nurses (P=0.01). A standardized admission order set is a simple, low-cost intervention that residents believe may benefit patients by reducing medical errors and expediting high-quality care.
    Journal of Hospital Medicine 02/2009; 4(2):90-6. · 1.40 Impact Factor
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    Arpi Bekmezian, Brigitte Gomperts
    Paediatrics & child health 12/2008; 13(9):775-7. · 1.03 Impact Factor
  • Arpi Bekmezian, Paul J Chung, Shahram Yazdani
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    ABSTRACT: To assess cost and length of stay for subspecialty patients on a staff-only general pediatric hospitalist service vs traditional faculty/housestaff subspecialty services in a major teaching hospital. Retrospective study of 2 cohort groups: a staff-only general pediatric hospitalist group and subspecialty faculty/housestaff gastroenterology and hematology/oncology groups. Major referral center providing full-spectrum, complex surgical, and subspecialty care including transplantation. Nine hundred twenty-five pediatric patients with gastroenterologic and hematologic/oncologic diseases admitted and discharged between July 1, 2005, and June 30, 2006. Main Exposure Patients with gastroenterologic and hematologic/oncologic diseases were assigned to the hospitalist team when faculty/housestaff teams reached their maximum census of patients per intern. Cost, length of stay, mortality, and readmission to the hospital within 72 hours of discharge. Cost averaged $11 000 and $16 500, respectively, for patients on the hospitalist service compared with those on nonhospitalist services. On average, length of stay was 7.2 days and 9.8 days, respectively. In negative binomial regression analyses controlling for subspecialty, demographic data, disease severity, and average daily census, patients on the hospitalist service had 29% lower costs (P < .05) and 38% fewer hospital days (P < .01) per admission compared with patients on subspecialty faculty/housestaff services, with no clear differences in mortality and readmission rates. Compared with the subspecialist faculty/housestaff system, the staff-only pediatric hospitalist system was associated with a marked reduction in cost and length of stay for patients with medically complex subspecialty diseases. In this era of resident duty-hour restrictions and medical complexity of conditions in inpatients, staff-only hospitalist programs may have a vital role in pediatric teaching hospitals.
    JAMA Pediatrics 10/2008; 162(10):975-80. · 4.28 Impact Factor