Practice variation in the management for nontraumatic pediatric patients in the ED

doi:10.1016/j.ajem.2008.11.021

The American Journal of Emergency Medicine

Volume 28, Issue 3, March 2010, Pages 275-283

https://doi.org/10.1016/j.ajem.2008.11.021 Get rights and content

Abstract

Study objective

To improve the management quality and monitoring for common pediatric illnesses in the general emergency department (ED), we examined the effect of physician specialty training on medical resource use and patient outcomes.

Methods

This was a retrospective cohort review of visits by children less than 18 years to the ED of 2 university-affiliated teaching hospitals. Clinical management by 2 groups (emergency physicians [EPs] and pediatricians each working 168 h/wk) was compared with respect to demographics, ED resource use, short-term outcome, disposition, direct ED costs for each visit, and frequency of radiographic and laboratory test use. The effects of medical decision making on resource use was assessed by comparing costs of radiographic studies, laboratory studies, and medication.

Results

Between-group differences in mean patient age, sex, and triage category were insignificant. Compared to pediatricians, EPs used radiographic and laboratory studies more frequently (respectively, 10.1% and 3.8% higher frequency and 90.5% and 7.6% higher cost) and less medication (12.5% lower cost). Patients managed by EPs had longer ED length of stay (LOS), higher admission rates to general wards, and shorter LOS per hospitalization but similar 72-hour revisit rates, needed more frequent referral for medical reasons, and left more frequently against medical advice.

Conclusion

Emergency physicians spent more time and medical resources and admitted patients at a higher rate. Emergency physicians and pediatricians managed critical patients similarly.

Introduction

Emergency physicians (EPs) and pediatricians often have significantly different training and practice settings. Their management of pediatric patients with common illnesses can be different [1], [2], [3]. These differences affect emergency department (ED) length of stay (LOS), ED cost, use of medical resources, and patient outcomes [4]. Previous studies examining unique diseases or diagnoses have found variations in clinical practice between EPs and pediatricians in pediatric EDs [1], [2], [3], [5]. However, few articles mention the differences in the management of emergency pediatric patients between EPs and pediatricians on the basis of extensive evaluation of demographics, variable diagnoses, use of medical resources, dispositions, and short-term outcome in the ED. Most nontrauma pediatric patients in Taiwan are evaluated in a separate part of the general ED. In this setting, 2 specialists treat pediatric patients as follows: EPs who treat patients of all ages, mainly adults, and pediatricians, who treat children only. Our previous study demonstrated that treatment by pediatric residents and attending physicians in the ED resulted in similar short-term outcomes, but pediatric residents spent more time and used more medical resources [6]. The role of the EP in providing emergency medical care to pediatric patients is evaluated in another prior article [7]. In this study, we investigated the effect of specialty training (emergency medicine vs pediatrics) on medical resource use, short-term outcomes, and dispositions stemming from the management of nontraumatic common pediatric illnesses in a general ED to find ways to improve the quality of monitoring and care.

Section snippets

Study design

This was a retrospective cohort review of visits to the ED by pediatric nontrauma patients. Our study protocol was reviewed by our institutional review board and deemed exempt from the requirement to obtain informed consent.

Study setting and population

The settings of this study were 2 university-affiliated teaching hospitals with EDs staffed by board-certified emergency medicine and pediatric attending physicians. At both sites, physicians provided 24-hour management of pediatric short-term nontrauma patients in a

Characteristics of study subjects

During the study period, the medical data for 27 487 patients were collected. There were 629 patients who were excluded based upon incompleteness of data. Finally, 26 858 patients were enrolled into this study. Of these patients, 13 966 were directly managed by EPs (group 1) and 12 892 were managed by pediatricians (group 2). Table 1 shows their demographics. There were insignificant between-group differences in mean age, sex, and triage category.

Costs and medical resources

Direct costs per visit were 9.6% higher in group

Overview

It was reported that physicians in the ED may manage pediatric patients differently because of their training [5], [10], [11]. Moreover, these differences could influence medical resource use [1] and indirectly influence ED LOS [1], [12], ED costs [1], [2], and even outcomes [2], [12], [13].

Our study demonstrated that pediatric patients in the ED treated by EPs (when compared to those treated by pediatric physicians) had comparable outcomes, but they also had longer ED LOS, used more resources

Conclusions

Compared to pediatricians, EPs spent more time, used more medical resources to treat pediatric patients in the ED, and admitted patients at a higher rate. Revisit rates within 72 hours were similar for patients in both groups. Emergency physicians and pediatricians managed critical patients similarly. More detailed study on the investigation of factors influencing the clinical care of pediatric emergency patients by physicians with different specialties should be implemented in the future.

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In developed countries such as Canada and the United States, most pediatric EDs are staffed by full-time pediatric ED-trained and credentialed attending physicians.3 Previous studies focusing on legal issues reported a decrease in malpractice claims and disbursements in a pediatric ED with full-time attending physician coverage;4 most studies of the quality of pediatric ED care have examined differences between residents and attending physicians or between emergency and pediatric physicians.5–9 The aim of quality in health care is “the degree to which health care services for individuals and populations increase the likelihood of desired health care outcomes and are consistent with current professional knowledge” as defined by the Institute of Medicine.10
Pediatric emergency medicine is a young field that has established itself in recent decades. Many unanswered questions remain regarding how to deliver better pediatric emergency care. The implementation of full-time pediatric emergency physicians is a quality improvement strategy for child care in Taiwan. The aim of this study is to evaluate the quality of care under different physician coverage models in the pediatric emergency department (ED).
The medical records of 132,398 patients visiting the pediatric ED of a tertiary care university hospital during January 2004 to December 2006 were retrospectively reviewed. Full-time pediatric emergency physicians are the group specializing in the pediatric emergency medicine, and they only work in the pediatric ED. Part-time pediatricians specializing in other subspecialties also can work an extra shift in the pediatric ED, with the majority working in their inpatient and outpatient services. We compared quality performance indicators, including: mortality rate, the 72-hour return visit rate, length of stay, admission rate, and the rate of being kept for observation between full-time and part-time pediatric emergency physicians.
An average of 3678 ± 125 [mean ± standard error (SE)] visits per month (with a range of 2487–6646) were observed. The trends in quality of care, observed monthly, indicated that the 72-hour return rate was 2–6% and length of stay in the ED decreased from 11.5 hours to 3.2 hours over the study period. The annual mortality rate within 48 hours of admission to the ED increased from 0.04% to 0.05% and then decreased to 0.02%, and the overall mortality rate dropped from 0.13% to 0.07%. Multivariate analyses indicated that there was no change in the 72-hour return visit rate for full-time pediatric emergency physicians; they were more likely to admit and keep patients for observation [odds ratio = 1.43 and odds ratio = 1.71, respectively], and these results were similar to those of senior physicians.
Full-time pediatric emergency physicians in the pediatric ED decreased the mortality rate and length of stay in the ED, but had no change in the 72-hour return visit rate. This pilot study shows that the quality of care in pediatric ED after the implementation of full-time pediatric emergency physicians needs further evaluation.
Practice variations between emergency physicians and pediatricians in treating acute bronchiolitis in the emergency department: A nationwide study
2015, Journal of Emergency Medicine
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The quality of care for pediatric emergency patients, including mortality, 72-h revisit rate, and length of ED stay, could not be assessed. A previous study showed that, although EPs used more medical resources to treat pediatric patients, the management of critically ill patients was similar to that of pediatricians (10). Third, nearly 60% patients were treated at community EDs.
Although supportive care is the mainstay management for acute bronchiolitis, non–evidence-based diagnostic testing and medications remain common in emergency departments (EDs).
Our aim was to compare emergency physicians (EPs) and pediatricians practice patterns in the management of acute bronchiolitis in the ED.
A cross-sectional study was conducted by using registration and claims datasets from 2008 to 2011. Patients with acute bronchiolitis were divided into EP group and pediatrician group.
A total of 2174 patients were enrolled. The diagnostic tests used, including chest x-ray (63.7% vs. 46%; adjusted odds ratio [OR] = 2.27; 95% CI 1.77–2.91), complete blood count (33.2% vs. 21.8%; adjusted OR = 1.74; 95% CI 1.33–2.26), C-reactive protein (35.1% vs. 22.6%; adjusted OR = 1.79; 95% CI 1.38–2.33), blood culture (23.9% vs. 14.3%; adjusted OR = 1.79; 95% CI 1.33–2.39), and arterial blood gas (3.7% vs. 1.8%, adjusted OR = 2.38; 95% CI 1.21–4.67), were higher in the EP group than in the pediatrician group. Intravenous fluid administration was also higher in the EP group (20.8% vs. 3.5%; adjusted OR = 7.49; 95% CI 5.12–10.8). In addition, EPs more frequently arranged for hospital admissions (36% vs. 19.5%; adjusted OR = 2.51; 95% CI 1.15–3.26).
Both EPs and pediatricians had high rates of ordering diagnostic testing for acute bronchiolitis patients in ED. Compared with pediatricians, EPs used more diagnostic tests for the patients with acute bronchiolitis in ED.
Pediatric overtriage as a consequence of the tachycardia responses of children upon ED admission
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Thus, it is important to address the issue of overtriage of pediatric ED patients; we observed such overtriage in a previous study, and a modification of the vital sign criteria was postulated to be the primary reason [2]. Previous studies have documented the characteristics of pediatric ED patients and found that the average age of such patients is between 5 and 7 years, and the median age was approximately 3 years in our previous study group [2,14,17,18]. Within this age interval, measuring vital signs, especially heart rate, of pediatric patients is particularly difficult due to the strong confounding effects of emotional responses [19,20].
Overtriage has been observed among pediatric patients in emergency departments (EDs) under 5-level acuity pediatric triage systems. This study aimed to investigate the causes of overtriage and to provide suggestions for future amendments to such systems.
This study has a retrospective follow-up design in which 42 000 pediatric patients who were admitted to the ED of the largest medical center in Taiwan between January and December of 2010 were recruited. The study variables included patient demographics, chief concerns, individual vital signs (ie, blood pressure, heart rate, body temperature, respiratory rate, and O₂ saturation), triage level, ED final disposition, ED expenses, and total medical expenses. A logistic regression model was applied to explore the causes of overtriage and the effectiveness of a modified acuity system.
Approximately 13.6% of the pediatric ED visits were upgraded to acuity level 1 based on vital signs that included heart rate (97.3%). The strength of the trend association (odds ratio) between decreasing acuity urgency (from levels 1 to 5) and hospitalization increased from 0.73 (95% confidence interval, 0.72-0.75) with the Pediatric Triage and Acuity System (Ped-TTAS) to 0.57 (95% confidence interval, 0.55-0.59) with the modified Ped-TTAS, which downgraded acuity levels by excluding the weighting of vital signs. Further validation was accomplished by comparing the trend association between decreasing acuity urgency and total medical expenses (Ped-TTAS: β = − 0.13; modified Ped-TTAS: β = − 0.18).
Heart rate is prone to be affected by emotional responses among pediatric patients in certain specific age groups. Appropriate revisions of the pediatric triage system are suggested.
Headache in the pediatric emergency service: A medical center experience
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In the PED, detailed headache history and characteristics, family migraine history, and thorough physical and neurological examinations are less readily available than in office-based practice. The majority of ED physicians confronting children are often trained in adult care,13,14 and they have varying degrees of skill and experience. Meningitis is inflammation of the thin tissue that surrounds the brain and spinal cord.
Headache is a common complaint in children and is one of the most common reasons for presentation at a pediatric emergency department (PED). This study described the etiologies of patients with headache seen in the PED and determined predictors of intracranial pathology (ICP) requiring urgent intervention. A secondary objective was to develop rapid, practical tools for screening headache in the PED.
We conducted a retrospective chart review of children who presented with a chief complaint of headache at the PED during 2008. First, we identified possible red flags in the patients' history or physical examination and neurological examination findings. Then, we recorded the brain computed tomography results.
During the study period, 43,913 visits were made to the PED; in 409 (0.9%) patients, the chief complaint was headache. Acute viral, respiratory, and febrile illnesses comprised the most frequent cause of headache (59.9%). Six children (1.5%) had life-threatening ICP findings. In comparison with the group without ICP, the group with ICP had a significantly higher percentage of blurred vision (p = 0.008) and ataxia (p = 0.002).
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Ensuring diagnostic accuracy in pediatric emergency medicine
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Over the last decade, numerous studies have demonstrated a significant variation in practice in the pediatric ED (PED).6-9
Children often present to the emergency department with undifferentiated complaints, such as abdominal pain. The role of the emergency physician is to make an accurate and efficient assessment leading to diagnosis and management. Physician risk tolerance and decision methods have led to variations in practice and quality of care within the pediatric emergency department (PED). The use of evidence-based clinical algorithms to standardize and improve the quality of care delivered in the PED has increased significantly over the last decade. Using an example of a care map for children with suspected appendicitis, this article will demonstrate the incorporation of clinical prediction rules into clinical practice as a model for quality improvement in the PED.
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View all citing articles on Scopus

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Original ContributionPractice variation in the management for nontraumatic pediatric patients in the ED

Abstract

Study objective

Methods

Results

Conclusion

Introduction

Section snippets

Study design

Study setting and population

Characteristics of study subjects

Costs and medical resources

Overview

Conclusions

Ann Emerg Med

Ann Emerg Med

Am J Emerg Med

Ann Emerg Med

Am J Emerg Med

Lancet

Ann Emerg Med

An Esp Pediatr

Ann Emerg Med

Practice variation in the emergency management of croup

Pediatrics

Comparative practice of emergency medicine physicians and pediatric emergency physicians managing fever in young children

Pediatrics

Diagnostic test ordering in the evaluation of febrile children. Physician and environmental factors

Am J Dis Child

Differences in admission rates of children with bronchiolitis by pediatric and general emergency departments

Pediatrics

Physician variation in test ordering in the management of gastroenteritis in children

Arch Pediatr Adolesc Med

Comparative clinical practice of residents and attending physicians who care pediatric patients in the emergency department

Pediatr Emerg Care

Original Contribution
Practice variation in the management for nontraumatic pediatric patients in the ED