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Neuman M.I.,Harvard University | Alpern E.R.,Northwestern University | Hall M.,Childrens Hospital Association | Kharbanda A.B.,Childrens Hospitals and Clinics of Minnesota | And 6 more authors.
Pediatrics | Year: 2014

BACKGROUND AND OBJECTIVE: Nationally, frequent utilizers of emergency departments (EDs) are targeted for quality improvement initiatives. The objective was to compare the characteristics and ED health services of children by their ED visit frequency.METHODS: A retrospective study in 1,896,547 children aged 0 to 18 years with 3,263,330 visits to 37 EDs in 2011. The number of ED visits per child within 365 days of their first visit was counted. Patient characteristics (age, chronic condition) and ED care (medications, testing [laboratory and radiographic], and hospital admission) were assessed. We evaluated the relationship between patient characteristics and ED health services received with multivariable regression.RESULTS: Children with ≥4 ED visits (8%) accounted for 24% of all visits and 31% ($1.4 billion) of all costs. As visit frequency increased from 1 to ≥4, the percentage of children aged <1 year increased (12.1% to 33.2%) and the percentage of children without a chronic condition decreased (81.9% to 45.6%) (P < .001 for both). Children with ≥4 ED visits had a higher percentage of visits without medication administration (aside from acetaminophen or ibuprofen), testing, or hospital admission when compared with children with 1 visit (35.4% vs 29.0%; P < .001). Children with ≥4 ED visits who were aged <1 year (odds ratio: 3.8; 95% confidence interval: 3.7-3.9) and who were without a chronic condition (odds ratio: 3.1; 95% confidence interval: 3.0-3.1) had the highest likelihood of experiencing this type of visit.CONCLUSIONS: With a disproportionate share of pediatric ED cost and utilization, frequent utilizers, especially infants without a chronic condition, are the least likely to need medications, testing, and hospital admission. Copyright © 2014 by the American Academy of Pediatrics.


Medford-Davis L.N.,University of Pennsylvania | Eswaran V.,Baylor College of Medicine | Shah R.M.,Baylor College of Medicine | Dark C.,Section of Emergency Medicine
Annals of Emergency Medicine | Year: 2015

This review synthesizes the existing literature to provide evidence-based predictions for the future of emergency care in the United States as a result of the Patient Protection and Affordable Care Act, with a focus on emergency department (ED) visit volume, acuity, and reimbursement. Patient behavior will likely be quite different for patients gaining Medicaid than for those gaining private insurance through the Marketplaces. Despite the threat of the individual mandate, not all uninsured patients will enroll, and those who choose to enroll will likely be a different population from those who remain uninsured. New Medicaid enrollees will be a sicker population and will likely increase their number of ED visits substantially. Their acuity will be higher at first but will then revert to the traditionally high number of low-acuity visits made by Medicaid patients. Most patients enrolling through the Marketplace are choosing high-deductible health plans, and they will initially avoid the ED because of high out-of-pocket costs but may present later and sicker after self-rationing their care. Most patients gaining health coverage through the Affordable Care Act will be shifting from uninsured to either Medicaid or private insurance, both of which reimburse more than self-pay, so ED collections should increase. Because of the differences between Medicaid and Marketplace plans, there will be a difference in ED volume, acuity, and financial outcomes, depending on states' current demographics, whether states expand Medicaid, and how aggressively states advertise new options for coverage in Medicaid or state health insurance Marketplaces. © 2015 American College of Emergency Physicians.


Macias C.G.,Section of Emergency Medicine
Pediatric radiology | Year: 2011

During the past decades, the use of CT to diagnose conditions and monitor treatment in the pediatric setting has increased. Infants and children often require procedural sedation to maintain a motionless state to ensure high-quality imaging. Various medication regimens have been recommended to achieve satisfactory sedation for this painless procedure. While the incidence of adverse events remains low, procedural sedation carries the risk of serious morbidity and mortality. The use of evidence-based, structured approaches to procedural sedation should be used to reduce variation in clinical practice and improve outcomes.


Roy A.D.,Section of Emergency Medicine | Chen L.,Section of Pediatric Emergency Medicine | Santucci K.,Section of Pediatric Emergency Medicine
Pediatric Emergency Care | Year: 2011

Objective: The objective was to assess pediatric residents' attitudes toward and knowledge about medical malpractice before and after an educational intervention. Methods: A survey of pediatric residents at our academic tertiary-care center was conducted before and 6 months after an educational workshop. Results: Of 71 eligible residents, 46 (65%) completed surveys. Thirty-nine (85%) of the 46 original participants completed the follow-up survey. At baseline, 86% thought medical malpractice should be taught during residency. This proportion increased to 95% at follow-up. At baseline, 43% reported that fear of a malpractice claim affected their practice. At follow-up, 69% indicated that fear of malpractice affected their practice (P = 0.01), and 69% of these reported improved documentation. At baseline, 30% of participants correctly thought that a resident's level of training was not a factor in determining if standard of care was provided. This increased to 56% at follow-up (P = 0.01). The majority (91%) of baseline participants thought a physician would be notified of a claim within less than 2 years of the occurrence. The actual mean delay is 25 months. At follow-up, 71% thought a physician would be notified 2 years later or more. Conclusions: Pediatric residents are uncomfortable with their knowledge of medical malpractice and think it should be taught during residency. Confusion regarding responsibility to provide standard of care and underestimates of the likelihood of being sued and the time to notification of a suit support the need for malpractice education. An educational intervention improves background knowledge and self-reported documentation. © 2011 by Lippincott Williams & Wilkins.


Wanga G.S.,Rocky Mountain Poison and Drug Center | Yin S.,Rocky Mountain Poison and Drug Center | Shear B.,Section of Emergency Medicine | Heard K.,Rocky Mountain Poison and Drug Center | Heard K.,University of Colorado at Denver
Pediatrics | Year: 2012

Human glycol ether poisonings are sparsely reported in the medical literature. We describe a healthy 22-month-old boy who accidentally drank up to 330 mL of brake fluid containing a 75% bleed of various glycol ethers (5%-50% polyethylene glycol monomethyl ether, 15%-40% triethylene glycol monoethyl ether, 1%-30% triethylene glycol monomethyl ether, 1%-25% triethylene glycol monobutyl ether, 1%- 20% polyethylene glycol, monobutyl ether, 1%-20% triethylene glycol, and <10% of other glycol ethers). Within 4 hours, he became somnolent and developed a persistent metabolic acidosis. Thirty minutes later, he received 1 dose of fomepizole. Neither progression nor improvement in clinical or metabolic status was noted after the fomepizole. He received hemodialysis for 3 hours ∼8 hours after ingestion, and his symptoms resolved resulting in an uneventfully recovery. Copyright © 2012 by the American Academy of Pediatrics.

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