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ED Crowding Adversely Affects Patient Satisfaction

Key point: Dissatisfaction lasts throughout entire hospital stay.
Citation: Pines JM, Iyer S, Disbot M, et al. The effect of emergency department crowding on patient satisfaction for admitted patients. Acad Emerg Med. 2008;15:825-831.

Recent studies on emergency department overcrowding have shown adverse patient outcomes when patients are boarded in the emergency department. To address how patient satisfaction relates to ED overcrowding, these authors retrospectively reviewed Press Ganey satisfaction surveys that were completed by patients who were admit- ted through the ED at a single urban academic medical center during a two-year period. The authors correlated sat- isfaction data with validated ED crowding factors, such as hallway placement, boarding time, and waiting time.
Data were available for 1,501 hospitalizations—approxi- mately 15% of all patients admitted through the ED during the study period.

In logistic regression analysis, both ED hallway placement and prolonged ED boarding time (>4.7 hours) were associated with lower satisfaction with ED care and lower satisfaction with overall hospital care.
[Published in J Watch Emerg Med, October 3, 2008—Diane Birnbaumer, MD, FACEP.]

Normal CT in Kids with Blunt Abdominal Trauma? Send Them Home

Key point: The negative predictive value of a normal CT scan with newer-generation 16-slice scanners is 99.8%.
Citation: Awasthi S, Mao A, Wooton-Gorges SL, et al. Is hospital admission and observation required after a normal abdominal computed tomography scan in children with blunt abdominal trauma? Acad Emerg Med. 2008;15(10):895- 899.

The practice of admitting children with blunt abdominal trauma for 24 hours of observation was established in the era of early-generation computed tomography (CT). These authors assessed the value of this practice in children with normal findings on scans obtained with newer-generation 16-slice CT scanners.

In a prospective, observational cohort study at a level I trauma center, the authors evaluated 1,085 children (age <18 years) with blunt abdominal trauma and no evidence of pre- defined intra-abdominal injury on CT.
Of these patients, 737 (68%) were admitted for observation and 348 were discharged to home. All patients’ medical records were reviewed to identify return visits within 30 days of initial presentation. None of the discharged patients and two of the admitted patients developed delayed intra-abdominal injury. The negative predictive value of a normal abdominal CT scan was 99.8%.

Although this study was conducted in a high-volume trauma center with board-certified radiologists, the results likely can be generalized to non-trauma centers where radi- ologists who do not see many pediatric trauma patients and who might or might not be board certified interpret the CT scans. Good discharge instructions and follow-up are impor- tant to identify the few cases of low-grade intra-abdominal injury that might be missed.
[Published in J Watch Emerg Med, October 24, 2008— Diane M. Birnbaumer, MD, FACEP.]


When to Suspect Abuse in Children with Fractures

Key point: No single fracture type or location is specific for abuse.
Citation: Kemp AM, Dunstan F, Harrison S, et al. Patterns of skeletal fractures in child abuse: Systematic review. BMJ. 2008;337:a1518. (Comment in BMJ 2008;337:a1398.)

Deciding whether to initiate an investigation for suspected child abuse can be difficult. Underreporting might expose children to greater injury, but investigations disrupt families, regardless of the final determination.
Researchers systematically reviewed published studies that compared fractures resulting from physical abuse and from other causes in children <18 years. Review articles, consensus statements, expert opinion, and other methodologically weak studies were excluded; 32 studies were included.

Overall, fractures resulting from abuse were most common in infants and toddlers. Among femoral fractures, the mid-shaft of the femur was the most common fracture location in both abused and non-abused children. Metaphyseal femoral fractures were more common in abused than non- abused children. In children <15 months, spiral fractures were the most common type of abusive femoral and humeral fractures. Supracondylar humeral fractures were less likely to result from abuse than non-abuse.

After exclusion of children who were involved in motor vehicle crashes or violent trauma, the probability that a fracture was caused by abuse was 71% for rib fractures, 48% for humeral fractures, 30% for skull fractures, 28% for femoral fractures, and 25% for radial and ulnar fractures. In all cases of suspected abuse, a skeletal survey should be  performed, including oblique views of the chest to assess for rib fractures. The bottom line is that no single fracture type or location is specific for abuse. Clinicians must perform a careful assessment to determine whether the story fits the situation, particularly in children <18 months and in those who are not ambulatory.
[Published in J Watch Emerg Med, October 24, 2008— Kristi L. Koenig, MD, FACEP.]

Exposure to Nontraditional Pets: It’s a Jungle Out There

Key point: Education about home pets can reduce the risk of many infections.
Citation: Pickering LK, Marano N, Bocchini JA, et al. Exposure to nontraditional pets at home and to animals in public settings: Risks to children. Pediatrics. 2008;122(4): 876-886. 
Ownership of exotic nontraditional pets is on the rise in the U.S.
Although families might not consult pediatricians before getting such pets, there is an opportunity to teach parents about potential

In conjunction with the American Academy of Pediatrics’ Committee on Infectious Diseases, these authors examined original research and review publications to identify and summarize illnesses and injuries associated with exposure to nontraditional pets at home and to animals in public settings.
The article is packed with information, but the most important medical points are as follows:

  • Reptiles, amphibians, rodents, and baby poultry can be sources of Salmonella.
  • Rodents (e.g., hamsters) can carry lymphocytic choriomeningitis virus, Yersinia pestis, Yersinia pseudotuber- culosis, and Mycobacterium marinum and can cause many skin infections.
  • Animals at petting zoos and other public locations (malls, schools, fairs) can be sources of infection, particularly gastrointestinal infections (e.g., from Escherichia coli 0157, Campylobacter, Giardia).
  • Aggressive animal behavior can lead to bites, scratches, falls, and crush injuries, exposing children to infectious organisms ranging from Pasteurella and Capnocytophaga to fatal infections such as herpes B virus.
  • The degree to which nontraditional animals cause allergies is unclear, but allergy can be caused by sensitization to dander, scales, fur, feathers, excrement, and saliva as well as by flea

The information in this article makes a compelling case for discussing animal exposure during healthcare evalua- tions. The authors provide informative Web-based resources for families and references for guidelines for prevention of disease transmission from exposure to animals, including hand hygiene, adult supervision, teaching children about safety near animals, and extra precautions for young chil- dren, immunosuppressed people, elders, and pregnant women.

[Published in J Watch Pediatr and Adolesc Med, October 29, 2008—Peggy Sue Weintrub, MD.]

Abstracts In Urgent Care: December, 2008