Understanding Low-Acuity Visits to the Pediatric Emergency Department

<div><p>Background</p><p>Canadian pediatric emergency department visits are increasing, with a disproportionate increase in low-acuity visits locally (33% of volume in 2008-09, 41% in 2011-12). We sought to understand: 1) presentation patterns and resource implications; 2) parents’ perceptions and motivations; and 3) alternate health care options considered prior to presenting with low-acuity problems.</p><p>Methods</p><p>We conducted a prospective cohort study at our tertiary pediatric emergency department serving two provinces to explore differences between patients with and without a primary care provider. During four, 2-week study periods over 1 year, parents of low-acuity visits received an anonymous survey. Presentation times, interventions, diagnoses and dispositions were captured on a data collection form linked to the survey by study number.</p><p>Results</p><p>Parents completed 2,443 surveys (74.1% response rate), with survey-data collection form pairs available for 2,146 visits. Overall, 89.7% of respondents had a primary care provider; 68% were family physicians. Surprisingly, 40% of visits occurred during weekday office hours and 27.3% occurred within 4 hours of symptom onset; 67.5% of those early presenters were for injuries. Few parents sought care from their primary care provider (25%), health information line (20.7%), or urgent care clinic (18.5%); 36% reported that they believed their child’s problem required the emergency department. Forty-five percent required only a history, physical exam and reassurance; only 11% required an intervention not available in an office setting. Patients without a primary care provider were significantly more likely to present during weekday office hours (<i>p</i> = 0.003), have longer symptom duration (<i>p</i><0.001), and not know of other options (<i>p</i> = 0.001).</p><p>Conclusions</p><p>Many parents seek pediatric emergency department care for low-acuity problems despite their child having a primary care provider. Ensuring timely access to these providers may help reduce pediatric emergency department overuse. Educational initiatives should inform parents about low-acuity problems and where appropriate care can/should be accessed.</p></div

Motivations and perceptions about coming to the emergency department.

<p>PCP-, Patient does not have a primary care provider. PCP+, Patient does have a primary care provider p values represent significant differences between subgroups by Pearson’s chi-square test. * p = 0.001. ** p<0.001. *** p = 0.005.</p

Chief complaint, as reported by the parent.

<p>PCP-, Patient does not have a primary care provider (n = 210). PCP+, Patient does have a primary care provider (n = 1,854).</p

Examples of common Low-Acuity (PaedCTAS level 4 and 5) Presentations.

<p>PaedCTAS Paediatric Canadian Triage and Acuity Scale</p><p>Examples of common Low-Acuity (PaedCTAS level 4 and 5) Presentations.</p

Time of Presentation to the Emergency Department.

<p>PCP-Patient does not have a primary care provider (n = 223). PCP+, Patient does have a primary care provider (n = 1,890). D, Days (08:00–17:00). E, Evenings (17:00–24:00). N, Nights (24:00–08:00). * <i>p</i> = 0.003.</p

Duration of symptoms prior to presentation*.

<p>PCP-, Patient does not have a primary care provider (n = 250). PCP+, Patient does have a primary care provider (n = 2,134). * p<0.001.</p

Characteristics of study patients compared to all low-acuity patients and all emergency department patients during the study period.

<p>DCF Data Collection Form</p><p>PED Pediatric Emergency Department</p><p>hrs hours</p><p>MD Medical Doctor</p><p>Characteristics of study patients compared to all low-acuity patients and all emergency department patients during the study period.</p

A Spontaneous Missense Mutation in Branched Chain Keto Acid Dehydrogenase Kinase in the Rat Affects Both the Central and Peripheral Nervous Systems - Fig 6

<p><b>A</b>. Brains from wild type (left) and <i>frogleg</i> (right) were of similar size. Scale is in centimeters. <b>B</b>. Brain weights, however, differed in wild type (+/+) and homozygote (<i>frogleg</i>) rats of 4 weeks, 10 weeks and 7 months of age, being considerably smaller in the <i>frogleg</i> rats compared to their littermates at all ages tested (mean+SEM).</p

Appearance of <i>frogleg</i> homozygous rat at 20 days of age.

<p>The animal on the left shows the typical appearance of the <i>frogleg</i> pup, relative to a non-<i>frogleg</i> littermate on the right. Note the small size, the thin, rough coat, and the abnormal rotation of the hind limbs of the affected animal.</p

Linkage map of the <i>frogleg</i> locus on rat chromosome 1.

<p>Ideogram of rat chromosome 1, showing polymorphic markers in the region of the <i>Bckdk</i> gene. Nucleotide sequence positions were determined by locating original marker amplimer sequences to the RGSC 6.0 / rn6 July 2014 assembly of the rat genome. MLINK-derived maximum LOD scores and corresponding theta values indicate linkage distance to the disease locus. The analysis was based on 11 affected and 10 unaffected individuals. Significant linkage scores identifying the initial disease interval (> 3.0) are enclosed in the box.</p