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Objective: Disaster preparedness training has a small but growing part in medical education. Various strategies have been used to simulate disaster scenarios to safely provide such training. However, a modality to compare their effectiveness is lacking. The authors propose the use of checklists, which have been a standard in aviation safety for decades. Design: Residents at four different academic pediatric residency programs volunteered to participate in tabletop simulation of a timed, pediatric disaster scenario. Resident teams were required to properly triage and manage simulated patients. Care intervention requests corresponding to each of the patients were recorded on a premade checklist. Results: Thirty-six teams provided a total of 1,476 possible care intervention requests for three pediatric patients: one with crush injury, one with increased intracranial pressure, and a nonverbal child. Some interventions were more likely to be omitted than others, and some teams performed extra interventions. Twenty-five entries from the checklist intervention responses were missing, affecting three of the teams. On average, teams requested 65 percent, were prompted to request 11 percent, and missed 22 percent of all checklist interventions with only 2 percent of all items not being recorded. Chi-square tests were performed for each patient scenario using R software. Categories compared included total counts of "requested," "prompted," and "missed" responses. Chi-square values were all statistically significant (p value < 0.05). Conclusions: In the checklist use during a tabletop disaster simulation, the authors have demonstrated that the checklist allows trainees to receive near immediate feedback. This training exercise provided them an opportunity to explore their own preparedness for a disaster scenario in a low-stress environment and allows for evaluation of such preparedness in a safe environment.
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Original Contribution
Cost-effectiveness of point-of-care testing for dehydration in the
pediatric ED
Rachel E. Whitney, MD , Karen Santucci, MD, Allen Hsiao, MD, Lei Chen, MD, MHS
Department of Pediatrics, Section of Emergency Medicine, Yale University School of Medicine, New Haven, CT 06510
abstractarticle info
Article history:
Received 6 May 2016
Received in revised form 24 May 2016
Accepted 24 May 2016
Objectives: Acute gastroenteritis (AGE) and subsequent dehydration account for a large proportion of pediatric
emergency department (PED) visits. Point-of-care (POC) testing has been used in conjunction with clinical as-
sessment to determine the degree of dehydration. Despite the wide acceptance of POC testing, little formal
cost-effective analysis of POC testing in the PED exists.
We aim to examine the cost-effectiveness of using POC electrolyte testingvs traditional serum chemistry testing
in the PED for children with AGE.
Methods: This was a cost-effective analysis using data from a randomized control trial of children with
AGE. A decision analysis model was constructed to calculate cost-savings from the point of view of the
payer and the provider. We used parameters obtained from the trial, including cost of testing, admission
rates, cost of admission, and length of stay. Sensitivity analyses were performed to evaluate the stability of
our model.
Results: Using the data set of 225 subjects, POC testing results in a cost savings of $303.30 per patient com-
pared with traditional serum testing from the point of the view of the payer. From the point-of-view of the
provider, POC testing results in consistent mean savings of $36.32 ($8.29-$64.35) per patient. Sensitivity
analyses demonstrated the stability of the model and consistent savings.
Conclusions: This decision analysis provides evidence that POC testing in children with gastroenteritis-related
moderate dehydration results in signicant cost savings from the points of view of payers and providers com-
pared to traditional serum chemistry testing.
© 2016 Elsevier Inc. All rights reserved.
1. Introduction
Few elds of practice are as consistently innovative as the practice of
medicine. New technologies of diagnostics and treatments are frequent-
ly introduced into practice with the hope of improving patient care. The
costs of these changes, however, are not always examined before imple-
mentation. The ideal new technology is one that supports a low-
spending/high-performance hospital system [1]. Point-of-care (POC)
testing for serum electrolytes allows accurate and rapid results at a re-
duced cost compared with traditional laboratory testing [2].Thistech-
nology can be especially useful in the emergency department (ED),
where previous research has shown that the use of POC testing leads
to decreased time to medical decision making [3] and decreased length
of stay (LOS) [4] in select populations.
Acute gastroenteritis (AGE) accounts for almost 2 million annual
visits to pediatric emergency departments (PED) in the United States
and incursa large health care cost[5]. App ropriate treatmen t of children
with dehydration from AGE requires assessment of severity of symp-
toms and degree of dehydration.Often, the degreeof dehydration deter-
mines treatment course and disposition, that is, admission vs discharge
and oral vs intravenous hydration [6]. Although weight loss is accepted
as the most accurate method of determining degree of dehydration, this
is not always possible to determine in the emergency setting, where a
recent prior weight is usually not available. Consequently, other factors
are used to judge the severity of dehydration. These factors often in-
clude serum electrolyte measurements [7].
We aim to examine the cost-effectiveness of using POC electrolyte
testing vs traditional serum chemistry testing in the PED for children
with AGE. We predict that use of POC technology for AGE management
results in a cost savings from the points of view of the payer as well as
the provider.
American Journal of Emergency Medicine 34 (2016) 15731575
Fundingsource: This researchdid not receive any specicgrant from fundingagencies
in the public, commercial, or not-for-prot sectors.
☆☆ Financial disclosure: The authorshave no nancial relationshipsrelevant to this article
to disclose.
Conict of interest: The authors have no potential conicts of interest to disclose.
Corresponding author at: 100 York St, Suite 1F, New Haven, CT 06511. Tel.: +1 203
737 7433.
E-mail address: (R.E. Whitney).
0735-6757/© 2016 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine
journal homepage:
2. Methods
2.1. Decision analysis
We calculated the incremental cost-effectiveness using data from a
randomized controlled trial of children with AGE [8]. A model was con-
structed using parameters obtained in the trial, including cost of testing,
admission rates, and cost of admission (Figure). We performed the anal-
ysis from 2 points of view. First, we calculated costs based on the point
of view of the payer. Next, we looked at costs from the point of view of
the provider (ie, the hospital system). Cost data were obtained from var-
ious reference sources (Table).
2.2. Equipment costs
The POC device used for this study was the i-Stat Analyzer (Abbott
Point of Care, East Windsor, NJ), a handheld, cartridge-driven device ca-
pable of performing basic electrolyte and blood gas tests in less than 2
minutes. Each cartridge requires less than 0.1 mL of blood. Tests used
during the course of the study included basic electrolytes (sodium, po-
tassium, chloride, and bicarbonate), glucose, blood urea nitrogen, creat-
inine, ionized calcium, hematocrit, and basic blood gas analysis. The cost
of an i-Stat 7 cartridge to the payer is $8.59. These data were obtained
from our university health center.
A basic metabolic panel, which includes sodium, potassium, chlo-
ride, bicarbonate, blood urea nitrogen, creatinine, and calcium, costs
the payer $11.54 and has a result time of 1 hour for STAT orders and 4
hours for routine orders. These data were obtained from our university
health center.
2.3. Payer costs
We used an average admission cost of $1158.76 per day for an oth-
erwise healthy patient admitted for dehydration in the setting of AGE
(unpublished hospital data). We then multiplied this cost by 2.16
days, the average LOS for AGE admission at ouruniversity health center
(unpublished data), for a total admission cost of $2502.92. The cost and
LOS are on par with data from Pediatric Health Information System
(PHIS) data. The total cost of the hospital stay was multiplied by the
probability of admission for patients in the POC and serum testing
groups [8]. Cost data were obtained from our university health center.
The sentinel PED visit was not included in the cost. All costs are
expressed in US dollars.
2.4. Provider costs
We calculated the opportunity cost for the hospital based on de-
creased LOS in the POC group as measured by nursing hours saved.
The hourly wage for nursing staff in our university ED ranges from $35
to $70 per hour, based on experience and specic shift. The median
LOS for the POC group was 38.5 minutes, 95% condence interval
(14.3-55.0), shorter than the traditional serum testing group.
2.5. Sensitivity analysis
We performed 1-way sensitivity analyses to determine the stability
of our model. We used the 95% condence interval cutoffs [8] for ED
LOS, varied the rate of admission by 20% bidirectionally, and used the
low and high range of nursing salary.
3. Results
From the point of the view of the payer, the average cost per patient
using iSTAT was $784.48. The average cost using serum electrolytes was
$1087.78. Results of our decision model suggest that using POC testing
rather than traditional serum testing results in a cost savings of
$303.30 per patient (Figure). Sensitivity analysis for admission rate
shows stability of the model and consistent savings. Varying admission
rate by 20% bidirectionally gives a savings range of $225.99 to $378.40.
From the point-of-view of the provider, the time saved with POC
testing factored by average nursing salary shows a mean cost savings
of $33.60 per patient. Performing the sensitivity analysis with low and
high range of nursing salaries, the savings had a range of $8.40 to
$64.40 per patient.
Figure. Cost to individual payer in POC and serum testing groups.
Hypothetical cohort of 100 patients in each arm.
Probability of admission and discharge in each arm as calculated by
Hsiao et al [8].
Assumptions for decision analysis
Assumption Rate Reference
i-Stat cost $8.59 University data
Serum cost $11.54 University data
Admission cost $1158.76 PHIS data
Admission LOS for AGE 2.16 d PHIS data
Admission rate for i-Stat testing 31% Hsiao et al
Admission rate for serum testing 43% Hsiao et al
Nursing hourly wage range $35-70/h University data
ED LOS difference for i-Stat group 38.5 min/patient Hsiao et al
1574 R.E. Whitney et al. / American Journal of Emergency Medicine 34 (2016) 15731575
4. Discussion
Although widely studied in adult populations, scant data exist on
cost-effectiveness for POC testing in the pediatric population. We have
shown that using POC testing rather than traditional serum testing for
children presenting with gastroenteritis may result in cost savings
from the points of view of the payer as well as the provider.
The American Academy of Pediatrics set weight measurement as the
standard of dehydration assessment [9]. However, this parameter con-
tinues to be debated [10], and several measures have been offered as ad-
junct evaluation tools [11].Perhaps,mostwidelysupportedinliterature
is electrolyte testing to help evaluate degree of dehydration in children.
Although conicting results exist for blood urea nitrogen and creatinine
as markers for dehydration, bicarbonate is consistently shown to be de-
creased in moderate to severe dehydration [10,12,13] with a cutoff
value of less than 15 to 17 mmol/L indicative of moderate to severe de-
hydration [7,14,15]. These laboratory markers, in addition to the overall
clinical picture of the patient, are often incorporated to determine the
need for intravenous hydration. Given that earlier result time has been
linked to decreased time to medical decision making [4], it is possible
that intravenous uids were started earlier and more appropriately in
the POC testing group.
Our data also show that use of POC testing can lead to decreased cost
for the hospital by decreasing LOS and creating revenue potential
through bed and nursing availability. Decreased LOS and time to treat-
ment with use of POC testing have been shown consistently in adult
populations [4,16,17]. The same properties lead to increased through-
put and bed turnover in pediatric patients, as demonstrated in the
study by Hsiao et al [8].
5. Limitations
Our decision model is based on data from a single randomized con-
trol trial set in an urban tertiary care children's hospital and is therefore
not necessarily generalizable to all PED settings.
A major contributor to overall cost savings in our model was the de-
crease in admission rates for the POC testing group. Admittedly, this is
not a consistent nding in theavailable literature. One possible explana-
tion for this is that shorter time to institute appropriate treatment based
on laboratory data leads to more prompt improvement in clinical condi-
tion during the ED stay, thereby leading to decreased admission rates.
The cost data for laboratory testing and result time for testing are spe-
cic to our university health center. The relatively small sample size of the
randomized control trial model tempers our conclusions. The original
study was performed before the widespread availability of low-cost ge-
neric ondansetron [18]. As previously mentioned, cost savings from the
hospital perspective is subject to numerous variables that affect bed avail-
ability and nursing hours. Although this is challenging to quantify, deci-
sion model analysis has been proven as a reasonable assessment tool,
and our cost-savings results were found to be consistent after careful sen-
sitivity analysis.
6. Conclusion
This decision analysis provides evidence that POCtesting in children
with moderate dehydration from gastroenteritis results in signicant
cost savings from the points of view of payers and providers.
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... Another study examined the utility of a checklist in evaluating pediatric disaster training [19]. In this study, residents for four different academic pediatric residency programs volunteered to participate in a tabletop simulation of a timed, pediatric disaster scenario. ...
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Opinion statement Recent disaster incidents have shown that pediatric disaster preparedness is more important than ever. Children represent nearly 25% of our population and are one of the most vulnerable groups, making them likely to be victims in disaster incidents. However, in spite of repeated efforts to adequately address the needs of children after disasters, progress for pediatric disaster preparedness has lagged behind efforts to improve general disaster preparedness. Previous disasters have demonstrated that children should be considered as part of the general population when planning occurs. Pediatric expertise and participation in disaster planning and drills would be invaluable in addressing the unique needs of children during these incidents. Furthermore, in order to have a sufficient response to pediatric needs by prehospital providers during a disaster, adequate coordination for pediatric care among emergency medical services systems needs to exist. Recent research has been performed on pediatric disaster triage; pediatric disaster training; pediatric chemical, biological, radiological, nuclear, and explosive (CBRNE) events; pediatric decontamination; and pediatric disaster mental health. This work has advanced the knowledge for this very specialized field. However, further research is necessary to continually improve the quality of care that children receive during and after a disaster incident in the prehospital setting, as the pediatric population will very likely be impacted by disasters to come.
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An accurate assessment of the degree of dehydration in infants and children is important for proper decision-making and treatment. This emphasizes the need for laboratory tests to improve the accuracy of clinical assessment of dehydration. The aim of this study was to assess the relationship between clinical and laboratory parameters in the assessment of dehydration. We evaluated prospectively 200 children aged 1 month to 5 years who presented with diarrhea, vomiting or both. Dehydration assessment was done following a known clinical scheme. We enrolled in the study 200 children (57.5% were male). The mean age was 15.62±9.03 months, with more than half those studied being under 24 months old. Overall, 46.5% (93) had mild dehydration, 34% (68) had moderate dehydration, 5.5% (11) had severe dehydration whereas, 14% (28) had no dehydration. Patients historical clinical variables in all dehydration groups did not differ significantly regarding age, sex, fever, frequency of vomiting, duration of diarrhea and vomiting, while there was a trend toward severe dehydration in children with more frequent diarrhea (p=0.004). Serum urea and creatinine cannot discriminate between mild and moderate dehydration but they showed a good specificity for severe dehydration of 99% and 100% respectively. Serum bicarbonates and base excess decreased significantly with a degree of dehydration and can discriminate between all dehydration groups (P<0.001). Blood gases were useful to diagnose the degree of dehydration status among children presenting with acute gastroenteritis. Serum urea and creatinine were the most specific tests for severe dehydration diagnosis. Historical clinical patterns apart from frequency of diarrhea did not correlate with dehydration status. Further studies are needed to validate our results.
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Dehydration secondary to gastroenteritis is one of the most common reasons for office visits and hospital admissions. The indicator most commonly used to estimate dehydration status is acute weight loss. Post-illness weight gain is considered as the gold-standard to determine the true level of dehydration and is widely used to estimate weight loss in research. To determine the value of post-illness weight gain as a gold standard for acute dehydration, we conducted a prospective cohort study in which 293 children, aged 1 month to 2 years, with acute diarrhea were followed for 7 days during a 3-year period. The main outcome measures were an accurate pre-illness weight (if available within 8 days before the diarrhea), post-illness weight, and theoretical weight (predicted from the child's individual growth chart). Post-illness weight was measured for 231 (79%) and both theoretical and post-illness weights were obtained for 111 (39%). Only 62 (21%) had an accurate pre-illness weight. The correlation between post-illness and theoretical weight was excellent (0.978), but bootstrapped linear regression analysis showed that post-illness weight underestimated theoretical weight by 0.48 kg (95% CI: 0.06-0.79, p<0.02). The mean difference in the fluid deficit calculated was 4.0% of body weight (95% CI: 3.2-4.7, p<0.0001). Theoretical weight overestimated accurate pre-illness weight by 0.21 kg (95% CI: 0.08-0.34, p = 0.002). Post-illness weight underestimated pre-illness weight by 0.19 kg (95% CI: 0.03-0.36, p = 0.02). The prevalence of 5% dehydration according to post-illness weight (21%) was significantly lower than the prevalence estimated by either theoretical weight (60%) or clinical assessment (66%, p<0.0001).These data suggest that post-illness weight is of little value as a gold standard to determine the true level of dehydration. The performance of dehydration signs or scales determined by using post-illness weight as a gold standard has to be reconsidered.
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To describe the proportion of patients attending an accident and emergency department for whom blood analysis at the point of care brought about a change in management; to measure the extent to which point of care testing resulted in differences in clinical outcome for these patients when compared with patients whose samples were tested by the hospital laboratory. Open, single centre, randomised controlled trial. Blood samples were randomly allocated to point of care testing or testing by the hospital's central laboratory. The accident and emergency department of the Bristol Royal Infirmary, a large teaching hospital which cares for an inner city population. Representative sample of patients who attended the department between April 1996 and April 1997 and who required blood tests. Data collection was structured in 8 hour blocks so that all hours of the day and all days of the week were equally represented. The proportion of patients for whom point of care testing brought about a change in treatment in which timing was considered to be critical to clinical outcome. Mortality, the length of stay in hospital, admission rate, the amount of time spent waiting for results of blood tests, the amount of time taken to decide on management plans, and the amount of time patients spent in the department were compared between patients whose samples were tested at the point of care and those whose samples were sent to the laboratory. Samples were obtained from 1728 patients. Changes in management in which timing was considered to be critical occurred in 59 out of 859 (6.9%, 95% confidence interval 5.3% to 8.8%) patients in the point of care arm of the trial. Decisions were made 74 minutes earlier (68 min to 80 min, P < 0.0001) when point of care testing was used for haematological tests as compared to central laboratory testing, 86 minutes earlier (80 min to 92 min, P < 0.0001) for biochemical tests, and 21 minutes earlier (-3 min to 44 min, P = 0.09) for analyses of arterial blood gases. There were no differences between the groups in the amount of time spent in the department, length of stay in hospital, admission rates, or mortality. Point of care testing reduced the time taken to make decisions on patient management that were dependent on the results of blood tests. It also brought about faster changes in treatment for which timing was considered to be critical in about 7% of patients. These changes did not affect clinical outcome or the amount of time patients spent in the department.
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To evaluate the relative utility of clinical and laboratory parameters of dehydration in children for predicting the magnitude of percent less of body weight (PLBW), we studied 97 children who required intravenous fluids for acute dehydration. After a complete history and physical examination, the managing physician made a clinical estimation of dehydration for each child, based on a standard clinical scale. Serum electrolytes were obtained in all children prior to intravenous hydration therapy. PLBW was calculated after recovery from acute dehydration by comparing the weight on presentation to the emergency department with the weight measured at a follow-up visit when the child was judged well. Children were classified according to PLBW into three groups which reflect the categories in a standard clinical scale: mild = PLBW < or = 5 (n = 50), moderate = PLBW 6-10 (n = 30), and severe = PLBW > 10 (n = 17). The physician's clinical estimate of dehydration compared to PLBW had a sensitivity of 74% (95% confidence interval (CI): 60-85) for mild dehydration, 33% (95% CI: 17-53) for moderate dehydration, and 70% (95% CI: 44-89) for severe dehydration. There was a significant difference in the mean serum bicarbonate concentrations (HCO3) between the PLBW groups (P < 0.01). The sensitivity of the HCO3 < 17 mEq/L in predicting PLBW was 77% (95% CI: 58-90) for PLBW 6-10, and 94% (95% CI: 71-100) for PLBW > 10. The combination of the clinical scale and the serum bicarbonate identified all 17 children with PLBW > 10 and 90% (27 of 30) children with PLBW 6-10. Our data suggest that physicians should not rely solely on clinical assessment to rule out severe dehydration in children, and that obtaining a serum bicarbonate may improve the accuracy of predicting serious dehydration.
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Editor,—I read with interest Booth’s comments1 on my article2 and I take this opportunity to clarify our findings. Mackenzie et al ’s study3 was fundamentally different from ours. The degree of dehydration was assessed by junior doctors and not specialists; all children were inpatients “thought to be” 5% to 10% dehydrated (only 25% were) and no cases of severe …
Acute gastroenteritis (AGE) is one of the most common reasons for children seeking care in the emergency department (ED), accounting for nearly 2 million visits in the United States each year. For children with AGE and mild to moderate dehydration, oral rehydration therapy (ORT) is effective and recommended by the Centers for Disease Control and Prevention1 and American Academy of Pediatrics as first-line therapy. However, vomiting is common in children with AGE and may prevent the success of ORT. Ondansetron, which became available in generic formulation in 2006, is efficacious in reducing vomiting and the need for intravenous (IV) rehydration and hospital admission,2 but little is known about its effectiveness in real-world practice.
Geographic variation in per-beneficiary Medicare spending that cannot be explained by wages and the prices of other inputs to health care or by demographic and health characteristics, as described by Dartmouth researchers, has intrigued researchers and stimulated policy debates for years.1- 4 Without evidence that Medicare beneficiaries in high-spending areas have better health outcomes than those in low-spending areas, policy makers have asked whether low-spending areas were being penalized while high-spending areas were being inappropriately rewarded. Wouldn’t it make sense to adopt policies to reduce expenditures in high-cost areas, perhaps by paying physicians and hospitals in those areas less? Could a similar case be made to address geographic variation in private health insurance expenditures?
Devices are now available that are practical for point of care testing (PCT) in hospital settings. Previous studies in clinical settings, however, have failed to demonstrate a reduction in patients' length of stay (LOS) associated with the use of PCT. This randomized controlled study compared PCT with central laboratory testing in a hospital Emergency Department to assess the difference in patients' LOS. Patients randomized to PCT (n = 93) had a median stay of 3 h, 28 min (interquartile range [IR] 2:28 to 5:30), while those allocated to the central laboratory (n = 87) had a median stay of 4 h, 22 min (IR 3:04 to 5:47). The median stay associated with PCT was significantly shorter. Among patients who were destined to be discharged home, there was also a significantly shorter stay, but not among those who were destined to be admitted. It was concluded that the use of PCT can achieve significant time savings in an Emergency Department.