Section on Emergency Medicine abstracts from #AAP15 – Part 1

Prevalence and Predictors of Adverse Events in Pediatric Emergency Department Sedation: A Prospective, Multi Center Surveillance Study from the Pediatric Emergency Research Canada

Maala Bhatt MD, MS

• Procedural sedation is common, but rates of adverse events are not precisely known
• Multicenter prospective study in 6 Pediatric EDs in Canada in 6,295 patients
• 99.7 ASA I or II, NPO ≤6 hours 49%, 7% NPO for liquids at ≤2 hours
• 63.5% were ortho reduction – add in abscess, lacs, I&D you get up to 90+%
• Ketamine with or without midazolam was most common
• Overall 11.6% – desat 5.7% and vomiting 5%
• 1.1% serious adverse event – No deaths – only need for PPV
• Serious events more likely when pre-procedure opiates, fentanyl + ketamine, and propofol co-administered

Bottom line: Don’t stop giving pre-procedure opiates, just be aware that the risk of adverse events may increase. You will definitely increase the risk of adverse events of you give an opiate with ketamine.

Revisiting Pediatric Emergency Medicine Provider Efficiency: A Multivariable Model

Fareed Saleh, MD, FAAP

• Objective: Design a model to measure PEM provider efficiency
• Retrospective study in two sites 85K and 35K annual patient volume
• Providers worked 750-1800 hours/year
• They tracked multiple factors related to patient arrivals and provider shift-specific factors
• Provider category (PEM faculty vs others), billed procedures, start time of shift each accounted for >5% of variation

Bottom line: This is one of the first efforts in PEM to attempt to correlate RVUs with patient and provider related factors, admittedly limited at a single site

Increasing Treatment with Metered Dose Inhaler to Improve Efficiency of Care for Children with Mild‐Moderate Asthma in the Emergency Department

Ruth Abaya, MD, MPH, FAAP presenting for Joseph J. Zorc, MD, MSCE, FAAP

• Mild to moderate asthma patients that were ESI 3 and 4 were often put on 3 BTB duonebs – at CHOP ordered as a single 1 hour combo treatment
• Key driver was than many patients initially getting nebs went home with a MDI
• MDI are associated with decreased length of stay in the ED
• Used the standard CHOP asthma pathway
• They reduced proportion of asthmatics getting nebulized albuterol from 47% to 23%
• They also discharged 63% of patients in <3 hours (24 minute length of stay decrease overall)
• 17% reduction in asthma admission rate in ESI 3 and 4 patients

Bottom line: Albuterol MDI are appropriate for many ESI level 3 and 4 asthmatics and their use has the potential to reduce the length of stay in the ED as well as admission rate.

Variation in Test Ordering for Low Acuity Patients by Pediatric Emergency Department Providers

Kaynan Doctor, MD, FAAP

• Sought to evaluate test ordering variation across different providers
• They looked at CBC, blood culture, Urine culture and chest X-Rays
• >150,000 low acuity patients seen by 156 providers (12 NPs, 60 PEM trained, 84 non-PEM trained)
  • 73 providers had >5 years out of training
• Providers that saw <100 patients had considerable variability in testing rates (higher testing rates)
• Rates overall 5-11% level 4 and 5 ESI patients got a test
• Low acuity patients on multivariable analysis saw no difference in test rates based on provider class

Bottom line: Low acuity patients get a lot of tests ordered – but we still need to understand why these tests were ordered and the appropriateness of them.

Universal Screening for Sexually Transmitted Infections in Asymptomatic Teens Reveals a Low Prevalence of Infection in an Urban Pediatric Emergency Department

Monika K. Goyal, MD, MSCE, FAAP

• Adolescents are having lots of unprotected sex and often seek ED care – thus they are a vulnerable population for testing and treating
• Is ED based asymptomatic screening in a high prevalence community worthwhile?
• A slight majority of the patients were female (52%)
• More of the refusers of asymptomatic testing reported that they had never had sex before, were younger and were more likely to have private insurance
• The overall prevalence was 4.9% (16/326), sexually active by patient report 7.7%, high risk 10%
• Adjusted OR=4 for having STI for patients who preferred ED as a place to be seen primarily when they were sick
• High risk sexual behaviors adjusted OR=7.2 for having STI on asymptomatic screening
• Obviously study limited in a single site

Bottom line: Overall low STI prevalence, but odds of STI when asymptomatic increased when patients used the ED for their ill-care and those with self report of high risk sexual behaviors. Perhaps targeted interventions are warranted.

Cost Analysis of Clinically Important TBI Diagnosis in PECARN Intermediate Risk Head Trauma Patients

Anne O’Connor, MD, MSc

• Clinically important traumatic brain injuries are rare – and there are good tools for risk-stratification of need for CT
• 30% of children are intermediate risk for ciTBI – with recommendation of stay for observation vs CT
• Now we know that observation does not delay diagnosis nor increase length of stay. Though CT rates vary between centers, less CTs are ordered when patients are observed
• The investigators used cost-effectiveness analysis and investigated 3 intermediate risk ciTBI scenarios – estimation of current practice, all patients observed and all patients CT’ed theoretically from a purely diagnosis perspective
• Overall the observe all patients had a cheaper cost of care
• To find a single ciTBI it costs $100,000 to CT everyone immediately versus $11,000 for observing all
• Sensitivity analysis backs up observation as the preferred model

Bottom line: This cost effectiveness based model argues for observation of all intermediate risk for ciTBI patients – prospective studies are certainly needed.