Pediatric Emergency Department Use Research Articles

Pediatric Emergency Department Use by Adults With Chronic Pediatric Disorders

Pediatric Emergency Department Use by Adults With Chronic Pediatric Disorders

Screening for Developmental Delay in High-Risk Users of an Urban Pediatric Emergency Department

To determine whether screening children in an urban pediatric emergency department (PED) would lead to identification of previously undiagnosed developmental delay. This was a cross-sectional study of families presenting to an urban public hospital PED with children 6 to 36 months and no history of developmental delay. Children were screened for possible developmental delay using the Ages and Stages Questionnaire; parents completed an instrument that assesses 5 domains: communication, gross motor, fine motor, problem solving, and personal-social. Sociodemographic data were also obtained. One hundred thirty-eight children were enrolled, all accompanied by their mothers. Mean age of the children was 18.9 months; 51.5% were female; 56.8% of the mothers were high-school graduates; 59.9% were immigrants; 75.4% were Latino. Twenty-one percent did not have a regular source of primary care; 26.8% (95% confidence interval, 20.1%-34.8%) screened positive in at least 1 domain, with a trend toward the highest percentage of positive screens on the communication domain (z = 1.89, P = 0.059). In a simultaneous multiple logistic regression model including all predictor variables, child age of 12 to 30 months was associated with increased adjusted odds of positive screen (adjusted odds ratio, 8.4; 95% confidence interval, 1.4-48.9). Having a primary caregiver born in the United States was statistically significant for screening positive in at least 1 Ages and Stages Questionnaire domain (P = 0.03). Almost 30% of 6- to 36-month-old children presenting to an urban PED without prior developmental concerns screened positive for possible delay, suggesting the utility of performing routine developmental screening in the PED. Pediatric emergency department use alone may be an indication for screening. Further study is needed for feasibility of screening for delay in the PED.

Challenges to Accessing Pediatric Health Care in the Mississippi Delta

Increases in hospital emergency department use have been driven by insured patients with problems accessing primary care services. Access problems are especially pronounced in rural communities with health professional shortages. This qualitative study explored reasons for nonurgent pediatric emergency department use in the Mississippi Delta. Using a community-based participatory research framework, a semistructured survey was administered face-to-face in a hospital emergency department waiting room with parents/caregivers who brought their children. Interviews were done over 144 hours in 2-hour blocks covering regular "business hours" and "after hours" (evenings/weekends). Open-ended items allowed qualitative data to be gathered describing reasons for emergency department use and perceptions of urgency of the visit in the parents'/caregivers' own words. There were 112 children, with a response rate of 87%. The mean child age was 5.7 years; 52% were male; 95% were African American and 5% white; 80.6% had Medicaid/SCHIP, 7.8% commercial, and 3.9% other insurance; 7.8% were uninsured. Most (88%) had a usual source of pediatric care. Only 24.3% tried to obtain care before emergency department visit; 23.2% said their children required "urgent" care. Mean distance from home to usual source of care was 10 miles. Ten percent cited transportation as a barrier to keeping health care appointments; 5.5% cited insurance or cost. Families who used the emergency department during evening/weekends were significantly more likely to have cited clinic hours of operation as a reason care was not sought previously than were "business hours" users, who emphasized convenience. Nonurgent pediatric emergency department use could be reduced by extending clinic hours, adding a walk-in service, and making transportation more available.

Pediatric Emergency Department Use by Adults With Chronic Pediatric Disorders

To describe pediatric emergency department use by adults with chronic pediatric disorders, known as transition patients. Retrospective descriptive study. The pediatric emergency department of a tertiary care pediatric hospital during calendar year 2005. All patients presenting to the pediatric emergency department during the study period. Association of presenting complaint with the patient's chronic pediatric disorder, emergency department interventions and dispositions, and duration of inpatient admissions. Patient encounters totaled 43 621, with 445 (1%) involving adult patients. Transition patients accounted for 197 (44%) of the adult encounters. Eighty-nine transition patient encounters (45%) were for complaints unrelated to the patients' chronic pediatric disorders. Only 14 (7%) transition patient visits did not involve diagnostic studies or procedures. Transition patients were 2.1 times (95% confidence interval, 1.8-2.5; P < .001) more likely to require admission than pediatric patients and were 4.5 times (95% confidence interval, 3.3-6.1; P < .001) more likely to require intensive care. Median length of stay for admitted transition patients was 4 days (range, 1-35 days) compared with 2 days (range, 1-80 days) for pediatric patients (P < .001). A substantial number of adult patients with chronic pediatric disorders use the pediatric emergency department and often present with complaints unrelated to their pediatric conditions. They have high rates of hospital and intensive care unit admissions. Pediatric hospitals should be prepared with adequate resources and training to deal with these complex adult patients.

Cochrane Review: Rapid viral diagnosis for acute febrile respiratory illness in children in the Emergency Department.

BackgroundPediatric acute respiratory infections (ARIs) represent a significant burden on pediatric emergency departments (ED) and families. Most of these illnesses are due to viruses. However, investigations (radiography, blood and urine testing) to rule out bacterial infections and antibiotics are often ordered because of diagnostic uncertainties. This results in prolonged ED visits and unnecessary antibiotic use. The risk of concurrent bacterial infection has been reported to be negligible in children over three months of age with a confirmed viral infection. Rapid viral testing in the ED may alleviate the need for precautionary testing and antibiotic use.ObjectivesTo determine the effect of rapid viral testing in the ED on the rate of precautionary testing, antibiotic use and ED length of visit.Search strategyWe searched the Cochrane Central register of Controlled Trials (CENTRAL) (The Cochrane Library, 2009, issue 1) which contains the ARI Group's Specialized Register, MEDLINE (1950 to April Week 3 2009), EMBASE (1988 to Week 16, 2009), MEDLINE In‐Process & Other Non‐Indexed Citations (April 27, 2009), HealthStar (1966 to 2009), BIOSIS Previews (1969 to 2009), CAB s (1973 to 2007), CBCA Reference (1970 to 2007), and Proquest Dissertations and Theses (1861 to 2009).Selection criteriaRandomized controlled trials (RCTs) of rapid viral testing for children with ARIs in the ED.Data collection and analysisTwo review authors used the inclusion criteria to select trials, evaluate their quality and extract data. Missing data were obtained from trial authors. Differences in rate of investigations and antibiotics use were expressed as risk ratios (RR) and difference in ED length of visits was expressed as mean difference, with 95% confidence interval (CI).Main resultsFour trials were included, three RCTs and one quazi‐RCT, with 759 children in the rapid viral testing and 829 in the control group. Rapid viral testing did not reduce antibiotic use in the ED significantly, neither clinically nor statistically. We found lower rates of chest radiography (RR 0.77, 95% CI 0.65 to 0.91) in the rapid viral testing group but no effect on length of ED visits, blood or urine testing in the ED.Authors' conclusionsCurrent evidence is insufficient, although promising, to support routine rapid viral testing as a means to reduce antibiotic use in pediatric EDs. Results suggest that rapid viral testing may be beneficial but are not statistically significant due to lack of power. A large trial addressing these outcome measures is needed.Plain Language Summary Does rapid viral testing in the Emergency Department affect the treatment of children with fever and respiratory problems? Children admitted to Emergency Departments (ED) with fever and respiratory symptoms represent a major burden to the health care system, as well as significant anxiety and expense to parents and caregivers. Physicians often order diagnostic tests and may prescribe antibiotics when they are unsure of the cause of the illness and are concerned about the possibility of serious bacterial infection. However, in most cases, fever and respiratory symptoms are caused by viruses. In addition, in children in whom a virus is found to be the cause of their illness, the risk of serious bacterial infection is very low. This review was conducted to assess whether a rapid viral test done in the ED changes what physicians do when treating these children. We found that in previously healthy children coming to the ED with fever and respiratory symptoms, a rapid viral test reduces the use of chest X‐rays and that there is a trend toward less antibiotic usage, and blood and urine investigations. The true impact of this intervention on the latter three outcomes requires trials with larger enrollment numbers.

Barriers and supports to implementation of MDI/spacer use in nine Canadian pediatric emergency departments: a qualitative study

BackgroundDespite recent research supporting the use of metered dose inhalers with spacer devices (MDI/spacers) in pediatric emergency departments (PEDs) for acute exacerbations of asthma, uptake of this practice has been slow. The objectives of this study were to determine the barriers and supports to implementing MDI/spacer research and to identify factors associated with early and late adoption of MDI/spacers in Canadian PEDs.MethodsUsing a comparative case study design, we classified nine tertiary care pediatric hospital PEDs based on their stage of implementation. Data were collected using focus group interviews with physicians, registered nurses (RNs), and respiratory therapists (RTs), and individual interviews with both patient care and medical directors at each site. Initial coding was based on the Ottawa Model of Research Use (OMRU) categories of elements known to influence the uptake of innovations.ResultsOne hundred and fifty healthcare professionals from nine different healthcare institutions participated in this study. Lack of leadership in the form of a research champion, a lack of consensus about the benefits of MDI/spacers among staff, perceived resistance from patients/parents, and perceived increased cost and workload associated with MDI/spacer use were the most prevalent barriers to the adoption of the MDI/spacer. Common strategies used by early-adopting sites included the active participation of all professional groups in the adoption process in addition to a well-planned and executed educational component for staff, patients, and families. Early adopter sites were also more likely to have the MDI/spacer included in a clinical protocol/pathway.ConclusionPotential barriers and supports to implementation have been identified that will help EDs adopt MDI/spacer use. Future interventions intended to increase MDI/spacer use in PEDs will need to be sensitive to the barriers identified in this study.

Impact of a Health Literacy Intervention on Pediatric Emergency Department Use

The aim of this study was to measure the impact of a simple parent health literacy intervention on emergency department and primary care clinic usage patterns. Study participants consisted of parents who brought their children to the Harbor-UCLA Medical Center pediatric emergency department for nonurgent complaints. Study participants filled out questionnaires regarding their management of children's mild health complaints and where respondents first seek help when their children become sick. After completing the questionnaires, participants were educated about how to use the health aid book What to Do When Your Child Gets Sick and provided a free copy. After 6 months, telephone follow-up interviews were conducted to assess whether the health literacy intervention had influenced the participants' management of their children's mild health complaints and their health care resource usage patterns. One hundred thirteen parents were enrolled in the preintervention phase, and 61 were successfully interviewed at 6 months by telephone. Before and after comparisons demonstrated a 13% reduction in the percentage of respondents who stated they would go to the emergency department first if their child became sick. In addition, 30% fewer respondents reported actual visits to the emergency department in the previous 6 months. Regarding specific low-acuity scenarios, significantly fewer participants would take their child to the emergency department for a low-grade fever with a temperature of 99.5 degrees F and for vomiting for 1 day. There was no significant change in the proportion of parents who would take their child to the emergency department for earache or cough. Health literacy interventions may reduce nonurgent emergency department visits and help mitigate emergency department overcrowding and the rising costs of health care.

Effect of Telephone Calls From Primary Care Practices on Follow-up Visits After Pediatric Emergency Department Visits

To test whether follow-up phone calls to counsel families about pediatric emergency department (PED) use and primary care availability made after an index PED visit would modify subsequent PED use. Longitudinal prospective randomized intervention. An urban academic children's hospital. A total of 4246 individuals aged 0 to 21 years from each of 4 participating primary care practices recording an index PED visit from April through December 2005. Follow-up phone call from the primary care practice within 72 hours of the initial PED visit to counsel about the availability of after-hours advice and when to access the PED. All subsequent visits to primary care practices, PED, pediatric subspecialists, or for inpatient hospitalization during a 365-day follow-up period. Logistic and ordinary least squares regressions estimated unadjusted and adjusted odds ratios of follow-up visits, controlling for covariates. Of the 2166 intervention subjects, 816 (37.7%) recorded follow-up PED visits compared with 819 (39.4%) of the 2080 control subjects (P = .26, not significant). The adjusted odds of a follow-up visit being to the PED rather than to another venue was significantly less for intervention than for control subjects (odds ratio, 0.88; confidence interval, 0.82-0.94), indicating decreased intensity of PED use. Follow-up phone calls from primary care practices after PED visits counseling patients on the use of primary care and emergency services can modulate subsequent care-seeking behavior and decrease future PED use.

What Brings Newborns to the Emergency Department?

Characterization of newborn visits to the pediatric emergency department (PED). Analysis of the main illnesses and establishment of association between certain conditions and severity of diseases. Retrospective study information concerning newborns (aged <28 days) who presented to the PED of Hospital Central de Faro during 2005. We studied the clinical and demographic data referring to the PED's episode and to perinatal occurrences. A total of 540 neonates visited the PED (1.5% of the total PED use), with an average age of 14.0 days and a slight prevalence of males (53.1%). Of the total visits, 17.2% were primary physician referrals. The chief complaints were jaundice, excessive crying, and rash. Diagnostic tests were requested in 27.2% cases. The major diagnoses were nonapparent disease, infant colics, and physiologic jaundice. In 13.0%, hospital admission was necessary. Newborns with referral, those with less than 37 weeks of gestation and those whose delivery weight was less than 2500 g, were more likely to be admitted. Most PED visits were because of nonserious diseases, mainly because of insufficient caretaker knowledge and information. This highlights the great need for caretakers' education by health staff. It is also important that physicians are aware of the main illnesses in the newborn period and know how to correctly identify the conditions associated to serious pathology.

Development of Measures of the Quality of Emergency Department Care for Children Using a Structured Panel Process

Performance measures are essential components of public reporting and quality improvement. To date, few such measures exist to provide a comprehensive assessment of the quality of emergency department services for children. Our goal was to use a systematic process to develop measures of emergency department care for children (0-19 years) that are (1) based on research evidence and expert opinion, (2) representative of a range of conditions treated in most emergency departments, (3) related to links between processes and outcomes, and (4) feasible to measure. We presented a panel of providers and managers data from emergency department use to identify common conditions across levels of patient acuity, which could be targets for quality improvement. We used a structured panel process informed by a literature review to (1) identify condition-specific links between processes of care and defined outcomes and (2) select indicators to assess these process-outcome links. We determined the feasibility of calculating these indicators using an administrative data set of emergency department visits for Ontario, Canada. The panel identified 18 clinical conditions for indicator development and 61 condition-specific links between processes of care and outcomes. After 2 rounds of ratings, the panel defined 68 specific clinical indicators for the following conditions: adolescent mental health problems, ankle injury, asthma, bronchiolitis, croup, diabetes, fever, gastroenteritis, minor head injury, neonatal jaundice, seizures, and urinary tract infections. Visits for these conditions account for 23% of all pediatric emergency department use. Using an administrative data set, we were able to calculate 19 indicators, covering 9 conditions, representing 20% of all emergency department visits by children. Using a structured panel process, data on emergency department use, and literature review, it was possible to define indicators of emergency department care for children. The feasibility of these indicators will depend on the availability of high-quality data.

Detection of Maternal Alcohol Use Problems in the Pediatric Emergency Department

Maternal alcohol use problems may impact the health and well-being of children, but often remain unrecognized. Mothers of young children seldom seek outpatient care for themselves; thus, pediatric settings may present an opportunity for the detection of maternal alcohol use problems. This study examines the feasibility of screening for and prevalence of alcohol use problems in mothers of young children in the context of seeking pediatric emergency care. We also examined the relationship of maternal alcohol use problems with use of pediatric emergency care. A total of 361 English-speaking mothers of children aged 7 and younger completed screening measures during their child's emergency care visit. TWEAK was used to screen for alcohol use problems. The screening survey also included information on children's health status and health care use, demographics, and the Center for Epidemiological Studies Depression Scale. Of the women approached, 90% agreed to complete the screening measure. On the basis of cutoff score of 2 or more, 7% of women had elevated TWEAK scores. Those women with a TWEAK score > 2 reported greater use of the pediatric emergency department (PED) than women scoring below the cutoff. On the basis of multivariate analyses, significant predictors of recent PED use included the presence of child chronic illness, younger maternal age, and TWEAK score. Screening for alcohol use problems among mothers of young children using the TWEAK appears to be feasible in a busy PED setting. The PED setting is promising for identifying risk drinking among women who may be less likely to be otherwise detected and for whom alcohol use may be impacting child outcomes.

Maternal and Child Factors Affecting High-volume Pediatric Emergency Department Use

To describe maternal and child characteristics associated with high-volume nonurgent pediatric emergency department (ED) use. We surveyed female caregivers of children aged 1 to 14 years who were brought to the ED at an urban medical center for nonurgent conditions. We analyzed characteristics associated with low-volume (1 ED visit) or high-volume (> or = 2 ED visits) use within the past year. Independent factors included predisposing, reinforcing, and enabling factors. Logistic regression was used to model high-volume ED use. Of the 300 participants (84% response rate), 99 were low-volume users and 201 were high-volume users. Most participants were mothers (94%). In adjusted analyses, high-volume use was associated with caregivers being single [odds ratio (OR), 2.57; 95% confidence interval (CI), 1.13-5.80], having high-volume ED use for themselves (OR, 2.02; 95% CI, 1.08-3.80), seeking care primarily in the pediatric ED for "sick visits" (OR, 2.47; 95% CI, 1.12-5.49), and lack of weekend hours at their child's usual source of care (OR, 2.58; CI, 1.24-5.37). Marital status, high maternal use of the ED, perception of the ED as the place to seek care for a sick child, and lack of weekend hours for usual source of care are associated with high-volume ED use among children. Given similarities in patterns of ED use among mothers and children, further attention is needed to address clinical practice and system issues that contribute to familial use of EDs.

Epidemiology of Pediatric Emergency Department Use at an Urban Medical Center

Dramatic increases in emergency department (ED) use contribute to rising healthcare costs and decrease continuity of care in the United States. Yet little is known about the acuity, frequency of visits, and demographic characteristics of children using the ED. This study examines general demographic trends over a 3-year period and examines whether there are factors associated with varying acuity at an urban academic pediatric ED. Analysis of administrative ED records from fiscal years (FY) 1999 to 2001 for children 0 to 18 years was performed to assess demographic characteristics, periodicity of ED use, and acuity level. Patient demographic characteristics, periodicity, and acuity were comparable for ED visits across each study year with approximately 25,000 annual visits. Among ED users in FY 2001, 42% sought urgent care exclusively, 12% received both urgent and nonurgent care, and 46% used the ED solely for nonurgent care. Of those with only nonurgent visits, 80% had 1 visit. In FY 2001, ED use was predominantly among patients who were black (77.3%) and were 1 to 4 years of age (35.4%). Relative to all patients, a greater percentage of those who used the ED exclusively for nonurgent care were black (87.2% vs. 76.0%, P < 0.05) and lived within 2 miles of the hospital (45.2% vs. 37.4%, P < 0.05). Nearly half of pediatric emergency visits are for nonurgent care. Racial disparities in use of the ED for nonurgent care may be related to patient's proximity to the hospital. Patterns of use are stable across the 3 years. Further study is needed to identify mutable factors in emergency care use.

Use of intravenous methohexital as a sedative in pediatric emergency departments.

To evaluate the effectiveness and safety of intravenous methohexital as a sedative in children undergoing emergency computed tomographic scans. Case series. An urban pediatric emergency department at a level I trauma center. Patients receiving intravenous methohexital for sedation to undergo emergency computed tomographic scans. Descriptive data were generated, including demographics, doses administered, times of sedation, outcomes, and complications. Data are reported from a total of 55 patients. The doses administered ranged from 0.5 mg/kg to 2.0 mg/kg (mean +/- SD, 1 +/- 0.5 mg/kg). Onset of sedation was rapid (mean +/- SD, 1 +/- 0.4 minutes), sedation was brief (mean +/- SD, 12 +/- 5 minutes), and the mean +/- SD length of the drug's effects was 14 +/- 6 minutes. Sedation was effective in most cases, and only a few patients had complications. Intravenous methohexital is a short-acting and effective sedative for use in pediatric emergency departments to obtain computed tomographic scans.

Early neonatal presentations to the pediatric emergency department.

As a result of shorter postpartum hospital stays, many medical concerns, which traditionally have been managed in newborn nurseries, are presenting to the pediatric emergency department (PED). We undertook a study to determine the profile of early neonatal visits to the PED. In addition, we examined the influence of maternal factors and length of postpartum hospital stay on PED visits. We conducted a retrospective chart review of all neonates < or = 8 days of age who presented to the PED between June 1990 and May 1995. Data gathered from neonatal and corresponding maternal charts included neonatal and maternal demographics, prenatal instruction, length of postpartum stay, source of referral, age at presentation, presenting complaint, diagnosis, disposition, and course in hospital, if admitted. A total of 559 neonatal visits were identified. Neonatal use of the PED increased 245% compared to an overall increase in PED use of 8.7% during the study period. Jaundice, difficulty breathing, feeding problems, and irritability were the most common presenting complaints while the most frequent diagnoses were normal physiology, jaundice, feeding problems, and query sepsis. Our overall admission rate was 33%. Self-referred patients were at a significantly lower risk of serious illness (16% admitted vs 49 % of consult patients). The self-referral rate increased with maternal age less than 21, single marital status, no prenatal classes, and primiparity. The length of postpartum hospital stay was identified in 389 neonates (55 early discharge (ED) and 334 non-early discharge (NED). The ED group had a significant increase in annual PED utilization compared to the NED group changing from 2% of the total population in study year 1 to over 31% in the final year. The ED and NED groups did not differ significantly with respect to the majority of chief complaints, frequency of PED diagnoses, admission rates, or maternal characteristics. Use of the PED by neonates < or = 8 days of age increased significantly over the study period. The majority of neonates presented by self-referral and were discharged with advice only. Mothers who were young, single, primiparous, or who had not attended prenatal classes presented with neonates who were less seriously ill. Although ED neonates represent an enlarging subset of PED visitors, they do not appear to differ significantly from NED neonates with respect to PED complaints, diagnoses, and disposition.

Diverting Managed Care Medicaid Patients From Pediatric Emergency Department Use

To evaluate the health outcomes of managed care Medicaid children with non-emergent conditions who were not authorized to be seen in the Pediatric Emergency Department (PED) by their primary care provider. Consecutive case surveillance from 6/29/92 to 2/2/93. University based PED (17,500 visits/year) in inner city Baltimore. Cases were MAC children denied authorization to be seen for non-emergent conditions in the PED. Age and complaint matched MAC children were selected from the university based Pediatric Ambulatory Center (PAC) and from non-emergent PED visits (PED-seen) in order to compare utilization rates after denial. The Maryland Access to Care (MAC) Medicaid program (started in 12/91) emphasizes primary care and appropriate health care utilization by incorporating the following elements of managed care: assignment to primary care provider, gatekeeping, mandatory enrollment and fee for service. Consecutive case surveillance from 6/29/92 to 2/2/93 was used to evaluate the health outcomes of MAC children denied authorization for non-emergent care in a university based PED. One week following denial, a pediatric nurse practitioner contacted the patient's caretaker and the MAC provider to ascertain health outcome. Medicaid claims data was used to compare the six month health care utilization of the denied group to age and complaint matched children seen in the PED (PED-seen) or in a primary care clinic (PAC). 216 MAC patients were not authorized for a PED visit by their MAC providers. 123 (57%) saw their MAC provider within one week of the denied PED visit. 40 (18%) were not seen because their presenting complaint had resolved completely. No adverse health outcomes occurred because of delay in health care delivery. The subsequent ER utilization rate of the denied group was the same as the PED-seen comparison group, and significantly higher than that of the PAC group (P = .002). The denied group was hospitalized at a significantly higher rate relative to these comparison groups (P = .003). Diverting Medicaid children classified as non-emergent in an ER to their MAC providers can be a safe practice short-term. However, denial of a PED visit has no impact on subsequent ER utilization by Medicaid participants and may be associated with higher hospitalization rate. Gatekeeping in this setting does not necessarily change the health care seeking behavior of these patients.

Why not your pediatrician's office? A study of weekday pediatric emergency department use for minor illness care in a community hospital.

To determine the rationale for using a community hospital's emergency department for minor illness care on weekdays, we surveyed 150 parents of children 15 years of age or younger. Fifty (33.3%) participants had no identified source of routine pediatric care, and 31 (20.7%) had pediatric providers not locally available. For participants with local providers, major reasons for use of the emergency department included economic factors, parental knowledge, parent/provider communication, convenience, and insurance coverage. The results of this study demonstrate that the utilization pattern and sociodemographic profile of children seen in our emergency department on weekdays is more characteristic of an inner-city hospital than of a non-metropolitan setting. There are a number of feasible measures which could improve access to routine pediatric care for low socioeconomic families and reduce unnecessary emergency department utilization.

Effect of season and weather on pediatric emergency department use

It is commonly believed that emergency department (ED) use is affected by extreme weather. To test this hypothesis, data concerning use of a pediatric ED during three seasonally diverse months was analyzed in the light of Weather Bureau information concerning daily conditions during the study months. Seven measures of extreme weather were defined: 1) extreme cold (daily high temperature ≤25°F); 2) extreme heat (daily high temperature ≥88°F); 3) unusual cold (winter) with departure from normal of mean temperature <−10°F; 4) unusual heat (summer) with departure from normal of mean temperature >10°F; 5) precipitation ≥0.25 inches (in water-equivalent inches); 6) stormy (thunderstorm, hail, ice, or blowing snow); 7) snow-covered (≥6 inches of snow on the ground). Seasonal use patterns were examined and the proportion of days with each weather factor was compared with the proportion of visits on days with the factor. The data indicate 1) season has a major affect on ED use because it affects prevalence of disease and injury; 2) extremely cold and stormy conditions significant reductions in ED use of approximately 5–20%; 3) 80–95% of expected visits are made on days with very bad weather. The data indicate that weather is a minor factor in determining ED use.

Has Medicaid promoted needless pediatric emergency department use?

The possibility that Medicaid has encouraged pediatric emergency department (ED) use was explored as part of a study of 8470 ED visits to a pediatric teaching hospital in the period from 1975 to 1976. The proportion of the population on Aid to Dependent Children (proportion on ADC) was taken as a reasonable proxy for prevalence of Medicaid coverage of children in an area. Visit subgroups were compared using mean proportions on ADC in the census tracts of origin to measure relative rates of ED use by poor children. If Medicaid has promoted use of the ED instead of other facilities, the data would be expected to indicate relatively heavy ED use by residents of tracts with a high prevalence of Medicaid: (1) during the week when other facilities are most available; and (2) for minor problems which do not result in admission. The data show no differences in the mean proportion on ADC in the census tracts of origin of ED visits on weekdays as compared to weekends or for visits which resulted in admission as compared with those which did not. The data challenge the idea that Medicaid has encouraged pediatric ED use.