[Show abstract][Hide abstract] ABSTRACT: Approximately 2% to 5% of children presenting to pediatric emergency departments (PEDs) leave prior to a complete evaluation. This study assessed risk factors for premature departure (PD) from a PED to identify key metrics and cutoffs for reducing the PD rate.
A 3-year cohort (June 2004-May 2007) of children presenting to a PED was evaluated. Children were excluded if they presented for psychiatric issues, were held awaiting hospital admission in the PED due to a lack of inpatient beds, were more than 21 years old, or died before disposition. Univariate analyses, multivariable logistic regression, and recursive partitioning were used to identify factors associated with PD. A fourth year of data (June 2007-May 2008) was used for validation and sensitivity analysis.
There were 132,324 patient visits in the 3-year derivation data set with a 3.8% PD rate, and 45,001 visits in the fourth-year validation data set with a 4.3% PD rate. PDs were minimized when average wait time was below 110 minutes, concurrent PDs were fewer than two, and average length of stay (LOS) was less than 224 minutes in the derivation set, with similar results in the validation set. When these metrics were exceeded, PD rates were over 10% among low-acuity patients. These findings were robust across a broad range of assumptions during sensitivity analysis.
The authors identified five key metrics associated with PD in the PED: average wait time, average LOS, acuity, concurrent PDs, and arrival rate. Operational cutoffs for these metrics, determined by recursive partitioning, may be useful to physicians and administrators when selecting specific interventions to address PDs from the PED.
Academic Emergency Medicine 11/2010; 17(11):1197-206. · 2.20 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Clavicle fractures are among the most common orthopedic injuries in children. Diagnosis typically involves radiographs, which expose children to radiation and may consume significant time and resources. Our objective was to determine if bedside emergency department (ED) ultrasound (US) is an accurate alternative to radiography.
This was a prospective study of bedside US for diagnosing clavicle fractures. A convenience sample of children ages 1-18 years with shoulder injuries requiring radiographs was enrolled. Bedside US imaging and an unblinded interpretation were completed by a pediatric emergency physician (EP) prior to radiographs. A second interpreter, a pediatric EP attending physician with extensive US experience, determined a final interpretation of the US images at a later date. This final interpretation was blinded to both clinical and radiography outcomes. The reference standard was an attending radiologist's interpretation of radiographs. The primary outcome was the accuracy of the blinded US interpretation for detecting clavicle fractures compared to the reference standard. Secondary outcome measures included the interrater reliability of the unblinded bedside and the blinded physicians' interpretations and the FACES pain scores (range, 0-5) for US and radiograph imaging.
One-hundred patients were included in the study, of whom 43 had clavicle fractures by radiography. The final US interpretation had 95% sensitivity (95% confidence interval [CI] = 83% to 99%) and 96% specificity (95% CI = 87% to 99%), and overall accuracy was 96%, with 96 congruent readings. Positive and negative predictive values (PPVs and NPVs, respectively) were 95% (95% CI = 83% to 99%) and 96% (95% CI = 87% to 99%), respectively. Interrater reliability (kappa) was 0.74 (95% CI = 0.60 to 0.88). FACES pain scores were available for the 86 subjects who were at least 5 years old. Pain scores were similar during US and radiography.
Compared to radiographs, bedside US can accurately diagnose pediatric clavicle fractures. US causes no more discomfort than radiography when detecting clavicle fractures. Given US's advantage of no radiation, pediatric EPs should consider this application.
Academic Emergency Medicine 07/2010; 17(7):687-93. · 2.20 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Previous literature suggests that process-related factors (eg, time of day, patient volume) and patient-related factors (eg, acuity, socioeconomic status) are associated with premature departure from emergency departments. We sought to evaluate the relationship of these and other factors with premature departure in a large, unselected cohort of pediatric emergency department patients.
This study was a retrospective cohort analysis of visits to a single tertiary site during a 1-year period. Patients' zip codes determined assignment of census-based socioeconomic metrics. Multivariate regression identified factors associated with premature departure. Sensitivity and subset analyses were performed. Return visits within 48 hours after premature departure were also reviewed.
There were 46,417 visits, of which 2164 were premature departures. In multivariate analysis, independent predictors of premature departures were arrival time, arrival month, arrival day of week, patient acuity, concurrent premature departures, arrival rate, arrival period average length of stay, and poverty rate. Aside from patient acuity and poverty rate, no patient-related factors were significant in multivariate analysis. These results were robust in sensitivity analysis across different multivariate models. Among premature departures, there were 120 return visits (5.5%), of which 15 were admitted (0.7%). There were no deaths. Acuity was similar between initial and subsequent visits.
Process-related factors and individual patient acuity have the strongest influence on premature departure from the pediatric emergency department. Health care organizations concerned with premature departure should focus efforts on improving pediatric emergency process flow.
Pediatric emergency care 05/2010; 26(5):349-56. · 0.92 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Overlap of the femoral artery (FA) on the femoral vein (FV) has been shown to occur in pediatric patients. This overlap may increase complications such as arterial puncture and failed insertions of central venous lines (CVLs). Knowledge of the anatomic relationship between the FV and FA may be important in avoiding these complications.
The objective was to evaluate the anatomic relationship of the FA and FV in straight leg position and frog leg position.
This was a prospective, descriptive study of a convenience sample of 80 total subjects (16 subjects from each of five predetermined stratified age groups). Each subject underwent a standardized ultrasound examination in both the straight and the frog leg positions. The location of the FA in relation to the FV was measured at three locations: immediately distal, 1 cm distal, and 3 cm distal to the inguinal ligament. Overlap of the FA on the FV and the diameter of the FV was noted at each location. Measurements were repeated in both the straight leg and the frog leg positions.
For the left leg, immediately distal to the inguinal ligament, the FV was overlapped by the FA in 36% of patients in straight leg position and by 45% of patients in frog leg position. At 1 cm distal to the ligament, overlap was observed in 75% of patients in straight leg position and 88% of patients in the frog leg position. At 3 cm distal to the ligament, overlap was observed in 93% of patients in straight leg position and 86% of patients in the frog leg position. The percentage of vessels with overlap was similar in the right leg at each location for both the straight and the frog leg positions. Pooled mean (+/-SD) FV diameters for the left leg immediately distal to the inguinal ligament were 0.64 (+/-0.23) cm in the straight leg position and 0.76 (+/-0.28) cm in the frog leg position; at 1 cm distal to the ligament, 0.66 (+/-0.23) and 0.78 (+/-0.29) cm; and at 3 cm distal to the ligament, 0.65 (+/-0.27) and 0.69 (+/-0.29) cm. FV diameters for the right leg were similar to the left.
A significant percentage of children have FAs that overlap their FVs. This overlap may be responsible for complications such as FA puncture with CVL placement. Ultrasound-guided techniques may decrease these risks. Placing children in the frog leg position increases the diameter of the FV visualized on ultrasound.
Academic Emergency Medicine 07/2009; 16(7):579-84. · 2.20 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Peripheral intravenous (PIV) catheter insertion is a frequent, painful procedure that is often performed with little or no anesthesia. Current approaches that minimize pain for PIV catheter insertion have several limitations: significant delay for onset of anesthesia, inadequate anesthesia, infectious disease exposure risk from needlestick injuries, and patients' needle phobia.
Comparison of the anesthetic effectiveness of J-Tip needle-free jet injection of 1% buffered lidocaine to the anesthetic effectiveness of topical 4% ELA-Max for PIV catheter insertion.
A prospective, block-randomized, controlled trial comparing J-Tip jet injection of 1% buffered lidocaine to a 30-minute application of 4% ELA-Max for topical anesthesia in children 8 to 15 years old presenting to a tertiary care pediatric emergency department for PIV catheter insertion. All subjects recorded self-reported visual analog scale (VAS) scores for pain at time of enrollment and pain felt following PIV catheter insertion. Jet injection subjects also recorded pain of jet injection. Subjects were videotaped during jet injection and PIV catheter insertion. Videotapes were reviewed by a single blinded reviewer for observer-reported VAS pain scores for jet injection and PIV catheter insertion.
Of the 70 children enrolled, 35 were randomized to the J-Tip jet injection group and 35 to the ELA-Max group. Patient-recorded enrollment VAS scores for pain were similar between groups (P = 0.74). Patient-recorded VAS scores were significantly different between groups immediately after PIV catheter insertion (17.3 for J-Tip jet injection vs 44.6 for ELA-Max, P < 0.001). Blinded reviewer assessed VAS scores for pain after PIV catheter insertion demonstrated a similar trend, but the comparison was not statistically significant (21.7 for J-Tip jet injection vs 31.9 ELA-Max, P = 0.23).
J-Tip jet injection of 1% buffered lidocaine provided greater anesthesia than a 30-minute application of ELA-Max according to patient self-assessment of pain for children aged 8 to 15 years undergoing PIV catheter insertion.
Pediatric emergency care 08/2008; 24(8):511-5. · 0.92 Impact Factor