Short-stay Observation Research Articles

Hospital costs and reimbursement for short-stay inpatient versus observation status hospitalizations for children with medical complexity.

There is a lack of uniformity across hospitals in applying inpatient versus observation status for short-stay (<48 h) pediatric hospitalizations, with negative financial implications associated with observation. Children with medical complexity (CMC) represent a growing population and incur high costs of care. The financial implications of inpatient and observation status for CMC have not been studied. To compare costs and reimbursement for short-stay hospitalizations for CMC by inpatient and observation status, overall and stratified by payor. We performed a cohort study of short-stay hospitalizations for CMC from 2016 to 2021 at 10 children's hospitals reporting reimbursement in the Pediatric Health Information System and Revenue Management Program. The primary outcome was the cost coverage ratio (CCR), defined as an encounter's reimbursement divided by the estimated cost. There were 89,282 encounters included. The median costs per encounter were similar across observation ($5206, IQR $3604-$7484) and inpatient ($6547, IQR $4725-$9349) encounters. For government payors, the median CCR was 0.6 (IQR 0.2-0.9) for observation encounters and 1.2 (IQR 0.8-1.9) for inpatient. For nongovernment payors, the median CCR was 1.6 (IQR 1.3-1.9) for observation and 1.6 (IQR 1.4-2) for inpatient. Government reimbursement was associated with increased risk for financial loss (OR 13.91, 95% CI 7.23, 26.77) and with a median net loss of $985,952 (IQR $389,871-$1,700,041) per hospital annually for observation encounters. Government-paid observation encounters for CMC are associated with significant financial loss at children's hospitals. This reimbursement model may pose a threat to children's hospitals'ability to care for CMC.

The impact of a non-restrictive Antimicrobial Stewardship Program in the emergency department of a secondary-level Italian hospital.

Evidence supporting the effectiveness of Antimicrobial Stewardship (AMS) Programs in the emergency department (ED) setting is limited. We conducted a prospective cohort study to assess the efficacy of an AMS program in an ED and a short-stay observation unit. The intervention included periodic prospective audits (twice a week), conducted by four infectious disease consultants. Primary outcomes included the difference in the hospital mortality rate, antibiotic consumption, and the incidence of bloodstream infections (BSI) caused by multidrug resistant (MDR) bacteria, before March 2020-February 2021 and after March 2021-February 2022 when the program was implemented. Interrupted time-series analysis was performed to assess the effect of our program. During the 12-month program, we performed 152 audits and evaluated 366 antibiotic therapies out of a total of 853 patients admitted. In the intervention period, we observed a non-statistically significant decrease in total antibiotic consumption, with a change in level of -31.2 defined daily dose/100 patient-days (PD) (p = 0.71). Likewise, we found no significant variations in the rate of BSI due to MDR Gram-positive (CT -0.02 events/PD, p = 0.84), MDR Gram-negative bacteria (CT 0.08, p = 0.71), or Candida spp. (CT 0.008, p = 0.86). Conversely, we found a significant decrease in the mortality rate between the pre- and post-intervention periods (-1.98 deaths/100 PD, CI -3.9 to -0.007, p = 0.049). The Antibiotic Stewardship Program in the ED was associated with a significant decrease in the mortality rate. More high-quality studies are needed to determine the most effective ASP strategies in this unique setting.

The use of pediatric short-stay observation in Italy

BackgroundIn Italy, the State Regions Conference on 1st August 2019 approved the Guidelines for Short-Stay Observation (SSO). At the beginning of 2022, the main Scientific Societies of the pediatric hospital emergency-urgency area launched a national survey to identify the extent to which these national guidelines had been adopted in the emergency rooms and pediatric wards of the Italian Regions.MethodsA survey has been widespread, among Pediatric Wards and Pediatric Emergency Departments (EDs), using both a paper questionnaire and a link to a database on Google Drive, for those who preferred to fill it directly online. Those who did not spontaneously answer, where directly contacted, via email and/or through a phone call and invited to participate. The data collected have been: age of managed children, presence of triage, presence of Sub-intensive Care Unit and Intensive Care Unit and special questions about Pediatric SSO, availability of training courses for workers, number of ED access in the last 4 years.ResultsThis survey is still ongoing, without a definite deadline, so we presented the preliminary data.Currently, 8/20 Regions have not yet adopted the Guidelines. Till 02 January 2023, data from 253 hospitals were collected. There are currently 180/253 active Pediatric SSO (71.03% of the Hospitals). There are not active SSO in 33.27% of first level ED, in 19.35% of second level ED and in 33.66% of General Hospitals with Pediatric Wards. Active SSO are located mainly (75.97%) within Pediatric Wards. At the moment, the survey has been completed in 16 Regions: in the 8 Regions which are using guidelines, pediatric SSOs are active in all the second level ED (compared to 60.87% of the other 8 regions), in the 91.66% of first level ED (compared to the 33.3%), and in the 97.1% of General Hospitals (compared to 33.3%), with a statistically significance (p < 0.0001).The territorial analysis of these 16 regions highlighted geographical differences in the percentage of SSOs active: 35.22% are active in hospitals in Southern Italy, 88.64% in Central Italy and 91.67% in those of the North.ConclusionsThe delay in adopting specific guidelines negatively influences activation of pediatric SSOs in hospital system and prevents the adjustment of welfare level to new needs. To facilitate the activation of SSOs in hospitals, it is also necessary to guarantee adequate economic recognition. It is essential to implement public interventions to overcome the current inequalities in the interest of children and their families: the current delay seriously penalizes emergency pediatric hospital care, especially in the southern Italian Regions.

Different Pediatric Acute Care Settings Influence Bronchiolitis Management: A 10-Year Retrospective Study

Bronchiolitis is the main cause of hospitalization in infants. Diagnosis is clinical, and treatment is based on hydration and oxygen therapy. Nevertheless, unnecessary diagnostic tests and pharmacological treatments are still very common. This retrospective study aimed to evaluate whether the setting of bronchiolitis care influences diagnostic and therapeutic choices. The management of 3201 infants, referred to our Italian Tertiary Care Center for bronchiolitis between 2010 and 2020, was analyzed by comparing children discharged from the pediatric emergency department (PEDd group) undergoing short-stay observation (SSO group) and hospitalization. Antibiotic use in PEDd, SSO, and ward was 59.3% vs. 51.6% vs. 49.7%, respectively (p < 0.001); inhaled salbutamol was mainly administered in PEDd and during SSO (76.1% and 82.2% vs. 38.3% in ward; p < 0.001); the use of corticosteroids was higher during SSO and hospitalization (59.6% and 49.1% vs. 39.0% in PEDd; p < 0.001); inhaled adrenaline was administered mostly in hospitalized infants (53.5% vs. 2.5% in SSO and 0.2% in PEDd; p < 0.001); chest X-ray use in PEDd, SSO, and ward was 30.3% vs. 49.0% vs. 70.5%, respectively (p < 0.001). In a multivariate analysis, undergoing SSO was found to be an independent risk factor for the use of systemic corticosteroid and salbutamol; being discharged at home was found to be a risk factor for antibiotic prescription; undergoing SSO and hospitalization resulted as independent risk factors for the use of CXR. Our study highlights that different pediatric acute care settings could influence the management of bronchiolitis. Factors influencing practice may include a high turnover of PED medical staff, personal reassurance, and parental pressure.

The benefit of a short-stay neurological observation unit in the COVID-19 era

Acute neurological symptoms are responsible for 5–15% of referral to the Emergency Department (ED). Since the COVID-19 outbreak, our stroke network shifted toward a mothership model with direct transport of stroke patients to the Comprehensive Stroke Center (“M. Bufalini” hospital, Cesena, Italy). To handle the increase in referrals due to mothership and guarantee a neurological fast-track in the ED, the Neurology service opened a four-bed Short-Stay Neurological Observation Unit (SSNO or “OBI Neuro”).

Gaming New Zealand's Emergency Department Target: How and Why Did It Vary Over Time and Between Organisations?

Background: Gaming is a potentially dysfunctional consequence of performance measurement and management systems in the health sector and more generally. In 2009, the New Zealand government initiated a Shorter Stays in Emergency Department (SSED) target in which 95% of patients would be admitted, discharged or transferred from an emergency department (ED) within 6 hours. The implementation of similar targets in England led to well-documented practices of gaming. Our research into ED target implementation sought to answer how and why gaming varies over time and between organisations. Methods: We developed a mixed-methods approach. Four organisation case study sites were selected. ED lengths of stay (ED LOS) were collected over a 6-year period (2007-2012) from all sites and indicators of target gaming were developed. Two rounds of surveys with managers and clinicians were conducted. Interviews (n=68) were conducted with clinicians and managers in EDs and the wider hospital in two phases across all sites. The interview data was used to develop explanations of the patterns of variation across time and across sites detected in the ED LOS data. Results: Our research established that gaming behaviour – in the form of ‘clock-stopping’ and decanting patients to short-stay units (SSUs) or observation beds to avoid target breaches – was common across all 4 case study sites. The opportunity to game was due to the absence of independent verification of ED LOS data. Gaming increased significantly over time (2009-2012) as the means to game became more available, usually through the addition or expansion of short-stay facilities attached to EDs. Gaming varied between sites, but those with the highest levels of gaming differed substantially in terms of organisational dynamics and motives. In each case, however, high levels of gaming could be attributed to the strategies of senior management more than to the individual motivations of frontline staff. Conclusion: Gaming of New Zealand’s ED target increased after the real benefits (in terms of process improvement) of the target were achieved. Gaming of ED targets could be minimised by eliminating opportunities to game through independent verification, or by monitoring and limiting the means and motivations to game.

Hospitalisation and morbidity due to adverse drug reactions in elderly patients: a single‐centre study

Adverse drug reaction (ADR) is a leading but under-recognised cause of illness, particularly in frail subjects with multiple comorbidities. To investigate the frequency, patterns and outcomes of ADR as a cause of hospitalisation in elderly patients admitted to an internal medicine ward. We performed a retrospective observational study including every patient aged over 65 years who was admitted to our department during a 12-month period. Patients admitted to short-stay (<24 h) observation unit were excluded. ADR accounted for 106 of total 1750 recorded admissions, which constituted a proportion of 6.1% (95% confidence interval 5.0-7.3%). The median age of patients was 83.5 (78.0-87.0) years and 56.6% were on polypharmacy. A total of 170 ADR was recorded with 45.3% of subjects experiencing concomitantly more than one ADR from a single molecule. Diuretics were the most commonly imputed molecules (30 events, 17.6%), followed by antithrombotics (25 events, 14.7%) and central nervous system-active drugs (16 events, 9.4%). Interactions were judged responsible for 39 cases of ADR (36.8%). An unfavourable outcome was observed in about one-third of patients (37.7%). Among those subjects, 11 (10.4%) died and 29 (27.4%) had residual disability. ADR are a common cause of hospital admission in elderly patients and are often associated with adverse outcomes. Our data underline the need of appropriate strategies aimed at identifying high-risk patients and avoiding potentially preventable drug toxicities.

First‐ever convulsive seizures in children presenting to the emergency department: risk factors for seizure recurrence and diagnosis of epilepsy

Aetiologies of first-ever convulsive seizures may be diverse, not all leading to recurrence or epilepsy diagnosis. We aimed to describe the epidemiology of first-ever convulsive seizures in children, investigating risk factors for recurrence and epilepsy diagnosis. This was a retrospective study of children presenting with a first-ever convulsive seizure to a tertiary-care paediatric emergency department (PED) in Italy, in a 12-month period (2011-2012). One hundred and eight children (57 males, 51 females) presented to the PED for a first-ever convulsive seizure; 90.7% were 6months to 6years old (median age 1y 10mo, mean 2y 7mo, range 0mo-14y 4mo). Seizure duration was less than 5minutes in 76.8%. Seizures were 'unprovoked' in 19.4% and 'provoked' in 80.6%. At 4-year follow-up, 37.9% of patients experienced recurrence and 13.6% received a diagnosis of epilepsy. Factors significantly associated with recurrence were the 'unprovoked' nature of the first seizure, multiple seizures in the first 24hours, positive family history of febrile seizures or epilepsy, and pre-existing neurological conditions/problems. Factors significantly associated with a diagnosis of epilepsy were the 'unprovoked' nature of the first seizure, age older than 6years, pre-existing neurological conditions/problems, and focal onset of first seizure. Children presenting to the PED with first-ever convulsive seizures represent a heterogeneous group. The identification of prognostic factors for recurrence and epilepsy diagnosis may help provide tailored counselling and follow-up. Seizures were 'unprovoked' in 19.4% and 'provoked' in 80.6% of children presenting to the emergency department. At 4-year follow-up, 37.9% relapsed, and 13.6% received a diagnosis of epilepsy. 'Unprovoked' first seizure, family history of febrile seizures, and pre-existing neurological conditions were associated with recurrence. 'Unprovoked' first seizure, age younger than 6years, and pre-existing neurological conditions were associated with epilepsy diagnosis.

Development of a paediatric short-stay observation and assessment unit.

In recent years children's emergency admissions have risen by 18%. In 2011 a team at a city district general hospital in England recognised that children were being admitted to the general children's ward and often only staying for short periods of time. After a review of the service a plan was put forward for the development of a paediatric short-stay observation and assessment unit. The unit has led to a reduction in ward admissions and offered opportunities for children's nurses to extend their roles in assessment and treatment. This article explores the planning, delivery and audit of this unit and offers an exemplar for other trusts considering a similar change to service delivery.

Factors Predicting Hospital Length of Stay Following Pharyngeal Flap for Velopharyngeal Insufficiency.

Routine hospital admission following pharyngeal flap (PF) to correct velopharyngeal insufficiency (VPI) is the standard at most hospitals. Nevertheless, there is increasing resistance from third-party providers to approve stays longer than a "short stay" (23-hour) observation period. The purpose of the current study was to evaluate length of stay (LOS) and document potential influencing factors following PF. Retrospective chart review. Demographic and perioperative data were collected, and statistical analyses were performed to determine associations with hospital length of stay (LOS). Readiness for discharge was determined by oral intake, analgesic requirement, and respiratory status. Tertiary care children's hospital Participants: All patients undergoing PF for VPI between 1990 and 2014. (1) LOS, (2) % satisfying all discharge criteria within a 23-hour observational time frame. Seventy-five patients were studied, with an average age of 6.8 years. Mean LOS was 65.4 hours. Only 11 patients (14.9%) met all discharge criteria by 23 hours. Multivariate predictors of shorter LOS were increasing patient age, male gender, lack of syndromic association, administration of an intraoperative antiemetic and steroids, and shorter anesthetic duration. Time to first oral intake correlated positively with LOS. Administration of intraoperative antiemetics increased the odds of meeting all discharge criteria within 23 hours by a factor of 12. Identification of factors associated with LOS after PF may allow providers to predict and potentially mitigate hospital stays. Nevertheless, most patients undergoing PF are not clinically ready for discharge within a short-stay (23-hour) observation period.

Use of a 23-hour emergency department observation unit for the management of patients with toxic exposures

BackgroundA significant proportion of patients with toxic exposures presenting to the ED require admission. However, most will improve within 24 hours, and so could potentially be managed in a short-stay...

Management of transient loss of consciousness of suspected syncopal cause, after the initial evaluation in the Emergency Department

The recommendations enclosed in the present document have been developed by a group of experts appointed by the &lt;em&gt;Gruppo Multidisciplinare per lo Studio della Sincope&lt;/em&gt; (Multidisciplinary Group for the Study of Syncope; GIMSI) and Academy of Emergency Medicine and Care (AcEMC). The aim is to define the diagnostic pathway and the management of patients referred to the Emergency Department (ED) for transient loss of consciousness of suspected syncopal cause, which is still unexplained after the initial evaluation. The risk stratification enables the physician to admit, discharge or monitor shortly the patient in the intensive short-stay Syncope Observation Unit (SOU). There are three risk levels of life-threatening events or serious complications (low, moderate, high). Low risk patients can be discharged, while high risk ones should be monitored and treated properly in case of worsening. Moderate risk patients should undergo clinical and instrumental monitoring in SOU, inside the ED. In all these three cases, patients can be subsequently referred to the Syncope Unit for further diagnostic investigations.

Pediatric emergency room activities in Italy: a national survey.

BackgroundIn Italy, the number of accesses to the Emergency Units has been growing for the past 30 years. This, together with a low coordination between hospital and peripheral pediatric services, has brought to an unnecessarily high number of hospital admissions. For this reason, it is essential to plan and implement strategies able to improve the appropriateness of hospital admissions. In the ’90s, the Short Stay Observation was extended to pediatric patients. As highlighted by the report “Guidelines for Pediatric Observation Units” (2005), patients receive considerable benefits from a short hospital permanence. The purpose of the study is to report data about the Pediatric Emergency Room activities in Italy.MethodsIn 2011, the Italian Society of Pediatrics promoted an online data collection to investigate organization and activity of Italian Pediatric and Neonatal Units. A form, containing 140 questions, was sent to 624 Pediatric and Neonatology Units. This study will be focused only on data regarding pediatric Emergency Rooms (E.R.) and Observation Units.Results237 units replied, 183 if we focus on units with pediatric inpatient service. Based on the results, E.R Units were provided with a dedicated pediatrician in 56 % of the cases: of these, 85 % for 24 h. The majority of the patients were seen by a pediatrician. In only 8 % of the units, patients visited by a pediatrician were less than 40 %. The age limit was 14 years in 60 % of the cases. In 72 % of participating units a E.R. triage was carried out. Only 18 % of units registered more than 10000 E.R. visits/year. The percentage of children hospitalized after accessing the E.R. was significantly higher in southern regions (more than 20 % of the units hospitalized more than 40 % of children entering the E.R.). 66 % of the units were provided with an Observation Unit. In 61 % of the cases, the duration did not exceed 24 h. In more than half of the structures, less than 10 % of the E.R. visits went into observation. The type of remuneration was not homogeneous.ConclusionsThe study highlights the heterogeneity of the Italian reality, with great possibilities for improvement, especially in southern regions.

Clinical Factors Affecting Length of Stay After 100 Consecutive Cases of Primary Cleft Lip Repair.

To analyze the hospital course of 100 consecutive infants after primary cleft lip repair (PCLR) and identify factors related to length of stay (LOS). Retrospective analysis of 100 consecutive infants who were routinely admitted after PCLR. Tertiary care center. One hundred consecutive infants undergoing PCLR. Demographic and perioperative data were collected and analyzed. LOS, planned before data collection. Male:female ratio was 65:35. Seventy-two infants had unilateral cleft lip; syndromic association was documented in 15 patients. Mean age and weight at PCLR were 5.6 ± 4.0 months and 6.7 ± 1.3 kg, respectively. Mean duration of surgery was 2.5 ± 0.9 hours, and mean duration of general anesthesia was 3.4 ± 0.9 hours. A total of 3.3 ± 1.5 mL of intraoperative local anesthetic was used per patient. Intravenous fluids were necessary after transfer from the post-anesthesia care unit to the general ward in 98% of patients. Almost half (44%) of all patients received intravenous morphine 23 hours or more after hospital admission. Mean LOS was 35.8 ± 13.9 hours. No association was identified between patient demographic factors and LOS. Multivariate linear regression models identified significant positive correlation between LOS and duration of general anesthesia (P = .002). Greater volume of postoperative oral intake (P = .000) and higher acetaminophen dosage on the floor (P = .000) correlated with decreased LOS. This study identifies perioperative factors associated with LOS. Our findings question the safety of routine outpatient or short-stay observation after PCLR.

Recurrent and high-frequency use of the emergency department by pediatric patients.

The authors sought to describe the epidemiology of and risk factors for recurrent and high-frequency use of the emergency department (ED) by children. This was a retrospective cohort study using a database of children aged 0 to 17 years, inclusive, presenting to 22 EDs of the Pediatric Emergency Care Applied Research Network (PECARN) during 2007, with 12-month follow-up after each index visit. ED diagnoses for each visit were categorized as trauma, acute medical, or chronic medical conditions. Recurrent visits were defined as any repeat visit; high-frequency use was defined as four or more recurrent visits. Generalized estimating equations (GEEs) were used to measure the strength of associations between patient and visit characteristics and recurrent ED use. A total of 695,188 unique children had at least one ED visit each in 2007, with 455,588 recurrent ED visits in the 12 months following the index visits. Sixty-four percent of patients had no recurrent visits, 20% had one, 8% had two, 4% had three, and 4% had four or more recurrent visits. Acute medical diagnoses accounted for most visits regardless of the number of recurrent visits. As the number of recurrent visits per patient rose, chronic diseases were increasingly represented, with asthma being the most common ED diagnosis. Trauma-related diagnoses were more common among patients without recurrent visits than among those with high-frequency recurrent visits (28% vs. 9%; p<0.001). High-frequency recurrent visits were more often within the highest severity score classifications. In multivariable analysis, recurrent visits were associated with younger age, black or Hispanic race or ethnicity, and public health insurance. Risk factors for recurrent ED use by children include age, race and ethnicity, and insurance status. Although asthma plays an important role in recurrent ED use, acute illnesses account for the majority of recurrent ED visits.

A&E clinical quality indicators: paediatric unplanned re-attendance rate

AimUrgent and emergency care is changing. The White Paper ‘Equity and excellence: Liberating the NHS’ proposed to focus on outcomes. New A&E Clinical Quality Indicators were introduced in 2011 to...

Home treatment of patients with acute cholecystitis

Background Patients with acute cholecystitis are treated in Hospital. The aim of the study was to analyze the security and efficacy of treating not-operated-on patients with acute cholecystitis in Hospital in the Home (HIH). Methods Prospective study from January 2010 to May 2011 including all patients diagnosed with acute cholecystitis, not operated on and without comorbidities admitted to HIH Unit from the Emergency Department Short Stay Unit and Observation Unit. Patients were treated with ertapenem for at least one week. Intravenous treatment was followed by oral therapy to complete 14 days of antibiotic treatment. Patient characteristics, clinical course, need for return to hospital during admission to HIH, and admission to hospital in the month after discharge from HIH are analyzed. Results 25 patients were included. Mean age was 59 years (34–82). Upon arrival to the Emergency Department, all patients suffered abdominal pain, 60% had fever, and 32% vomiting. 48% of patients had a leukocyte count over 13,000 cells/μl. All patients had cholelithiasis and a distended gallbladder. 56% showed thickening of the gallbladder wall. Fluid accumulation around the gallbladder was noted in 16% of the cases. Murphy's sign proved positive in 44%. All patients showed a favorable course. No patient required hospital readmission during stay in HIH or in the month after discharge. All patients expressed their satisfaction with treatment at home. Conclusions Patients with acute cholecystitis and without comorbidities can be safely and effectively treated in HIH after a short monitoring period in hospital.

Organisation et moyens de l’accueil des urgences pédiatriques : enquête nationale française en 2008

Organization and resource utilization of pediatric emergency departments (PEDs) have been poorly evaluated. To assess the access to appropriate pediatric emergency care in France and the degree of preparedness of PEDs and general emergency departments (GEDs) without separate pediatric emergency facilities. A closed-response survey was e-mailed and/or posted to 256hospitals with pediatric wards. A total of 120useable surveys were returned (93% of PEDs and 29% of GEDs). In the PEDs surveyed (n=67, 33university hospitals [UHs] and 34non-university hospitals), disease recruitment was medical and surgical with trauma (84%) or medical only (16%). The medical directors of the PEDs were pediatricians (99%). The average number of visits in 2007was 20,200±10,600per PED (+13% within 5years), and the average number of medical practitioners was 4±3. However, in only 76% of PEDs was at least one pediatrician present after midnight. Medical staffing of PEDs in UHs did not include a pediatric resident in 30% and a pediatric attending physician in 63% of these units. Approximately, 48% of PEDs had a short-stay observation unit (median, five beds). In GEDs (n=53), children were admitted 24h a day in the GED (41%) and directly in the pediatric ward during the day and in the GED at night (28%). Traumas were admitted in 98% of the GEDs. Pediatric coverage 24h a day is still insufficient in PEDs. The training and experience of pediatricians were restricted by the lack of pediatric residency and physician positions in pediatric emergency care. A different access to pediatric emergency care during the day and night was frequent in hospitals without a PED.

134 Management of Acute Pain in Paediatric Emergency Departments: A Survey of Policies in Italy

Aims: To explore the policies of Italian paediatric emergency departments (ED) towards management of acute pain in children. Methods: Eleven paediatric and two general hospitals with separate paediatric triage were recruited. Policies regarding pain management at time of triage and in the emergency clinical area were surveyed through a structured questionnaire. Information regarding the hospital and the ED were also collected. Multiple correspondence analysis (MCA) was carried out to explore relationships between variables related to pain management and hospital characteristics. The study was supported by Angelini ACRAF. Results: Six hospitals routinely carried out pain assessment at triage, and 7 in the emergency clinical area. Nine hospitals (69%) used validated tools such as FLACC (7 hospitals), Wong-Baker (7) visual analogic or visual numeric scales (8). EMLA cream for anticipated venous cannulation was used “sometimes” (10 to 50% of events) by 4 hospitals, and often (51 to 90%) by 1. MCA identified two main dimensions, explaining 85.3% of variance in pain management policies: 1) routine pain assessment, joint medical nursing protocols for pain treatment, and EMLA at least sometimes; and 2) pain measurement through validated tools and recording of results. Being a paediatric hospitals, university affiliation, medico-surgical and trauma emergency functions, global triage on a 24h basis, and possibility for short-stay observation were associated with higher scores on both dimensions. Conclusions: Despite a general awareness of the relevance of acute pain in children and widespread presence of protocols, use of validated tools and prophylaxis of procedural moderate pain are still insufficiently applied.

Syncope in the emergency department of a large northern Italian hospital: incidence, efficacy of a short-stay observation ward and validation of the OESIL risk score

ObjectiveSyncope causes 1–3% of all emergency department (ED) visits, a high percentage of hospitalisations and prolonged hospital stay; nevertheless, many cases remain unexplained.MethodsThis study analysed the incidence of syncope at...