RESUMEN
BACKGROUND: Emergency department (ED) visits provide an opportunity for hepatitis C virus (HCV) screening for patients who otherwise might not be tested. We report on a novel nontargeted, opt-out HCV screening and linkage-to-care (LTC) program implemented in an urban ED. METHODS: This is a descriptive analysis from 3 months (November 2016-January 2017) of a nontargeted, opt-out ED HCV screening and LTC program among patients at least 13 years old undergoing phlebotomy for clinical purposes. A multipurpose best practice advisory (BPA) alerted providers to the program and generated order labels. For patients who authorized testing, specimens were drawn in the ED for HCV antibody (Ab) and reflex confirmatory RNA tests. Public health navigators attempted to contact RNA-positive patients and arrange outpatient visits. RESULTS: HCV Ab tests were performed on 3,808 patients, a 6,950% increase from preprogram. The proportion of HCV Ab test positivity was 13.2% (504/3,808, 95% confidence interval [CI] = 12.2%-14.3%) and of those 97.8% (493/504) had a follow-up RNA test performed. A total of 292 were confirmed positive for active infection, for an overall RNA positivity rate of 7.7% (95% CI = 6.8%-8.5%). Of those with active infection, 155 (53%) were outside the Centers for Disease Control and Prevention birth cohort for increased risk for HCV including 46 (15.8%, 95% CI = 11.8%-20.4%) who also did not report injection drug use. Linkage attempts were documented on 223 (76.4%) patients and appointments were scheduled for 102 (38% of attempted). Sixty-six patients attended their LTC visit (22.5% of all RNA-positive patients, 30% of linkage-eligible patients). CONCLUSIONS: Nontargeted opt-out HCV testing can be successfully implemented in an ED setting. A number of patients diagnosed were outside traditional risk groups. Once diagnosed, an ED population may be difficult to engage in care, but a structured interdisciplinary program can successfully link patients to HCV care.
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Servicio de Urgencia en Hospital/estadística & datos numéricos , Hepatitis C/diagnóstico , Tamizaje Masivo/métodos , Adolescente , Adulto , Femenino , Hepatitis C/sangre , Hepatitis C/epidemiología , Anticuerpos contra la Hepatitis C/sangre , Humanos , Masculino , Persona de Mediana Edad , Desarrollo de Programa , Factores de Riesgo , Estados Unidos , Adulto JovenRESUMEN
Long-acting reversible contraception (LARC) is recommended as first-line contraception for adolescents and young adults. As the use of LARC increases, pediatric emergency medicine clinicians should be able to recognize different types of LARC and address their common adverse effects, adverse reactions, and complications. This continuing medical education activity provides an overview of LARC and will assist clinicians in the evaluation and management of patients with LARC-associated complaints.
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Dolor Abdominal/etiología , Anticoncepción/métodos , Servicio de Urgencia en Hospital , Dispositivos Intrauterinos Medicados/efectos adversos , Levonorgestrel/efectos adversos , Dolor Abdominal/diagnóstico , Adolescente , Anticonceptivos Femeninos/efectos adversos , Diagnóstico Diferencial , Femenino , Estudios de Seguimiento , HumanosRESUMEN
Stroke is rare in children but leads to significant morbidity and mortality. Emergency department physicians are likely to be the first to evaluate children suffering strokes and it is, therefore, important for them to recognize common presenting features and risk factors for pediatric stroke. This review describes the epidemiology, clinical presentations, stroke types, associated risk factors, evaluation, treatment, and prognosis of pediatric stroke. Further research is needed on the acute and preventative treatments of pediatric stroke because merely applying our knowledge of stroke in adults to children is insufficient.
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Accidente Cerebrovascular/diagnóstico , Factores de Edad , Niño , Preescolar , Diagnóstico Diferencial , Servicios Médicos de Urgencia/métodos , Cardiopatías/complicaciones , Humanos , Lactante , Recién Nacido , Factores de Riesgo , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/terapia , Trombofilia/complicacionesRESUMEN
BACKGROUND: Mental health problems in adolescents have been recognized as a significant medical concern. They have been associated with risk-taking behaviors during adolescence. OBJECTIVE: To determine the prevalence of elevated scores for psychological distress among adolescent girls aged 15 to 21 years who present to a pediatric emergency department (PED) for general medical care and to correlate psychological distress scores with sexual and substance use behaviors. METHODS: The study was performed in the PED of an urban general hospital. We enrolled female patients aged 15 to 21 years cared for in the PED. Subjects completed the Center for Epidemiological Studies-Depression Scale 8 (CES-D8); elevated scores were defined as 7 or greater. The survey collected data on demographics, sexual practices, alcohol and drug use, and health care access and utilization. RESULTS: Two hundred ninety-nine subjects participated. One hundred forty-one participants (47.7%) had CES-D8 scores of 7 or greater. In multivariate logistic regression, factors associated with increased emotional distress were being white, Hispanic, or of other race; having a recent new sex partner; and recent sex without birth control. Alcohol use in the past 3 months was associated with elevated distress as was having a distant relationship with one's parents/guardians. Those who had never had sex or who had sex in the past but not within the past 3 months were also more likely to have elevated CES-D8 scores compared with those who had sex more recently with the use of birth control. CONCLUSIONS: Screening for mental health issues in the emergency department may identify a significant number of adolescent patients in need of further evaluation, especially as half of surveyed patients reported the PED as a usual source of health care.
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Conducta del Adolescente , Depresión/epidemiología , Servicio de Urgencia en Hospital , Asunción de Riesgos , Estrés Psicológico/epidemiología , Adolescente , Consumo de Bebidas Alcohólicas/epidemiología , Consumo de Bebidas Alcohólicas/psicología , Conducta Anticonceptiva/psicología , Conducta Anticonceptiva/estadística & datos numéricos , Depresión/diagnóstico , Servicio de Urgencia en Hospital/estadística & datos numéricos , Emociones , Etnicidad/psicología , Etnicidad/estadística & datos numéricos , Relaciones Familiares , Femenino , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Hospitales Generales/estadística & datos numéricos , Hospitales Urbanos/estadística & datos numéricos , Humanos , Prevalencia , Índice de Severidad de la Enfermedad , Conducta Sexual/psicología , Conducta Sexual/estadística & datos numéricos , Trastornos Relacionados con Sustancias/epidemiología , Trastornos Relacionados con Sustancias/psicología , Poblaciones Vulnerables/psicología , Poblaciones Vulnerables/estadística & datos numéricos , Adulto JovenRESUMEN
Soft tissue infections frequently prompt visits to the pediatric emergency department. The incidence of these infections has increased markedly in recent years. The emergence of community-acquired methicillin-resistant Staphylococcus aureus is associated with an increasing morbidity, mortality, and frequency of abscess formation. Bedside ultrasound may have a significant impact in the management of patients that present to the pediatric emergency department with soft tissue infections, including cellulitis, cutaneous abscess, peritonsillar abscess, and necrotizing fasciitis. Ultrasound is an efficient, noninvasive diagnostic tool which can augment the physician's clinical examination. Ultrasound has been shown to be superior to clinical judgment alone in determining the presence or the absence of occult abscess formation, ensuring appropriate management and limiting unnecessary invasive procedures.
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Absceso/diagnóstico por imagen , Drenaje , Servicio de Urgencia en Hospital , Infecciones de los Tejidos Blandos/diagnóstico por imagen , Absceso/tratamiento farmacológico , Absceso/epidemiología , Absceso/cirugía , Antibacterianos/uso terapéutico , Celulitis (Flemón)/diagnóstico por imagen , Celulitis (Flemón)/tratamiento farmacológico , Celulitis (Flemón)/epidemiología , Celulitis (Flemón)/cirugía , Preescolar , Terapia Combinada , Fascitis Necrotizante/diagnóstico por imagen , Fascitis Necrotizante/tratamiento farmacológico , Fascitis Necrotizante/epidemiología , Fascitis Necrotizante/cirugía , Humanos , Staphylococcus aureus Resistente a Meticilina , Absceso Peritonsilar/diagnóstico por imagen , Absceso Peritonsilar/tratamiento farmacológico , Absceso Peritonsilar/epidemiología , Absceso Peritonsilar/cirugía , Sistemas de Atención de Punto , Valor Predictivo de las Pruebas , Sensibilidad y Especificidad , Enfermedades Cutáneas Bacterianas/diagnóstico por imagen , Enfermedades Cutáneas Bacterianas/tratamiento farmacológico , Enfermedades Cutáneas Bacterianas/epidemiología , Enfermedades Cutáneas Bacterianas/cirugía , Infecciones de los Tejidos Blandos/tratamiento farmacológico , Infecciones de los Tejidos Blandos/epidemiología , Infecciones de los Tejidos Blandos/cirugía , Infecciones Estafilocócicas/diagnóstico por imagen , Infecciones Estafilocócicas/tratamiento farmacológico , Infecciones Estafilocócicas/epidemiología , Infecciones Estafilocócicas/cirugía , UltrasonografíaRESUMEN
Examining the young child who presents to the emergency department with a visual or ocular complaint can be a challenge. This article discusses basic concepts of visual and behavioral development and methods for an accurate ocular examination in young children. Topics reviewed include conjunctivitis, orbital and periorbital cellulitis, lacrimal system infections, congenital issues, misalignment, and oncology.
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Conjuntivitis/diagnóstico , Servicio de Urgencia en Hospital , Oftalmología , Pediatría , Trastornos de la Visión/diagnóstico , Pruebas de Visión/métodos , Envejecimiento/fisiología , Niño , Preescolar , Conjuntivitis/tratamiento farmacológico , Conjuntivitis/fisiopatología , Humanos , LactanteRESUMEN
BACKGROUND: Bedside ultrasound (BUS) can provide critical information in a rapid and noninvasive manner to the emergency physician. It is widely used in emergency departments (ED) throughout the nation. Literature shows that BUS shortens patient stay and increases patient satisfaction. General emergency medicine (EM) residencies incorporate BUS training in their curricula. However, there are limited data about the training that pediatric emergency medicine (PEM) fellows receive. OBJECTIVE: To determine the extent of training and use of BUS in PEM fellowship programs. METHODS: A 29-question survey was mailed to all (57) PEM fellowship program directors in the spring of 2006. RESULTS: The response rate was 81% (46/57). Fifty-seven percent (26/46) of the responding PEM fellowship program directors reported that their faculty used BUS in their departments. At 50% (23/46) of programs, fellows perform BUS studies. Sixty-five percent (30/46) of PEM fellowships reported that their fellows receive some BUS training, but only 15 of these programs included BUS training in the curriculum as a 2- to 4-week ultrasound rotation.Sixty-five percent (30/46) of PEM fellowship programs had access to an ultrasound machine, but only 28% (13/46) of programs had their own machine. The main reason not to own an ultrasound machine was a lack of ultrasound expertise in their department (67%, 22/33). Bedside ultrasound training was provided by general EM physicians in 57% (17/30) of programs. Eighty-seven percent of the directors agree that BUS training would benefit their practice.The 2 factors significantly associated with the likelihood of having formal BUS training were access to an ultrasound machine (87% vs 55% P=0.04) and presence of an adult ED with an EM residency at the program (80% vs 42% P=0.03). Pediatric emergency medicine fellowship programs at children's hospitals were significantly less likely to have formal training (33.3% vs 74.2%; P=0.01). CONCLUSIONS: Despite literature supporting the benefits of BUS in the ED, many PEM fellowship programs do not incorporate BUS training for their PEM fellows. Most PEM fellows who receive training in BUS are instructed by physicians trained in EM, not PEM.
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Curriculum/normas , Medicina de Emergencia/educación , Becas , Internado y Residencia , Pediatría/educación , Sistemas de Atención de Punto , Ultrasonografía , Recolección de Datos , Equipos y Suministros de Hospitales/provisión & distribución , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Hospitales Pediátricos/estadística & datos numéricos , Humanos , Servicio de Radiología en Hospital/organización & administración , Ultrasonografía/instrumentación , Ultrasonografía/estadística & datos numéricos , Estados UnidosRESUMEN
BACKGROUND: Restraint of children and adolescents with psychiatric problems has generated controversy. Restraint may be defined as methods used to restrict movement or normal access to one's body. Published data to guide restraint practice are limited. OBJECTIVE: To examine frequency of restraint use and patient demographics and chief complaints associated with restraint use in our pediatric emergency department. METHODS: We retrospectively reviewed the pediatric emergency department records of children (age <18 years) who underwent emergency psychiatric evaluation in an urban general hospital from January 2001 to December 2002. Factors associated with restraint use were determined using multivariate logistic regression. RESULTS: Data were available for 1125 (82%) of 1371 patients who underwent emergency psychiatric evaluation; 76 (6.8%) of 1125 patients were restrained: 37 physical, 19 with medication, and 20 both. Study patients were mean age 13.1 years, 50% girls, 54% blacks, 19% Latinos, and 18% whites; 80% had public insurance. Boys were restrained more often than girls (8.7% vs. 5.2%, P = 0.02). Age, insurance, and race were not associated with restraint use. Patients admitted for inpatient psychiatric care were restrained more frequently than those discharged home (9.9% vs. 3.9%, P < 0.001). In multivariate logistic regression, sex was not associated with restraint use. Restraint use was associated with chief complaints of visual hallucinations (odds ratio, 5.29), out-of-control behavior (odds ratio, 4.65), hyperactivity (odds ratio, 2.26), and admission to a psychiatric facility (odds ratio, 2.40). CONCLUSIONS: Approximately 1 in 15 children undergoing psychiatric evaluation were restrained. This is the first study to elucidate correlates of restraint practice in the pediatric emergency department. Further studies examining indications for restraint and comparing methods of restraint are needed.
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Servicio de Urgencia en Hospital/estadística & datos numéricos , Trastornos Mentales , Pediatría , Restricción Física/estadística & datos numéricos , Adolescente , Femenino , Humanos , Modelos Logísticos , Masculino , Restricción Física/métodos , Estudios RetrospectivosRESUMEN
OBJECTIVE: To identify current practice and staff education regarding the use of restraint in emergency departments for children undergoing psychiatric evaluations and to compare restraint practice and education in emergency medicine residencies (EMRs) and pediatric emergency medicine fellowships (PEMFs). METHODS: A self-administered survey regarding staff and resident education and the use of restraint for emergency pediatric patients undergoing psychiatric evaluation was mailed to the directors of EMRs and PEMFs. Main outcome measures included frequency of restraint use, staff trained in restraint use, favored positions for physical restraint, and agents regularly used for chemical restraint. RESULTS: Forty-one percent (48/118) of EMRs and 66% (33/50) of PEMFs completed the survey. The great majority of both EMRs and PEMFs report use of physical and chemical restraint in 5% or less of pediatric psychiatric patients. Forty of 47 EMRs and 29 of 32 PEMFs have formal policies on physical restraint use. Far fewer programs have formal policies for chemical restraint (13/33 EMRs and 5/28 PEMFs). A large percentage of both EMRs and PEMFs do not teach their trainees about the application of restraints (EMR = 52%, PEMF = 82%) or the appropriate situations in which to use restraint (EMR = 35%, PEMF = 64%). However, EMRs were more likely than PEMFs to teach about both appropriate restraint application and appropriate situations for their use (RR = 2.6, 1.2-5.8 and RR = 1.8, 1.1-2.9, respectively). The supine position was the position favored by both groups for physical restraint. Therapeutic holding was infrequently used, mostly for younger children. Seventy-two percent of EMRs and 85% of PEMFs used chemical restraint in children. Benzodiazepines and butyrophenones were the most commonly used agents. However, butyrophenones were often misclassified as phenothiazines by both EMRs and PEMFs. CONCLUSION: Restraint, both physical and chemical, is a widely, but uncommonly used, intervention for pediatric psychiatric patients in emergency departments. Many EMRs and PEMFs do not teach residents about restraint.