ORIGINAL ARTICLE

Adult Patients in the Pediatric Emergency Department Presentation and Disposition Wendalyn K. Little, MD, MPH*† and Daniel A. Hirsh, MD‡§

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There are several scenarios by which PEM providers could find themselves caring for adult patients in the pediatric ED (PED). The Emergency Medical Treatment and Active Labor Act (EMTALA) passed in 1986 requires a medical screening examination for any patient requesting care in an ED.2 Although intended to prevent “patient dumping” of uninsured patients, this law has also led to an interpretation by many health care entities that any patient presenting to the ED must be seen and evaluated and any emergency conditions must be stabilized before transfer to another facility.3,4 Previous studies have attempted to gauge the impact of EMTALA legislation on adult visits to PEDs, and at least 1 found a trend toward increasing visits by adult patients after the passage of the legislation.5 Furthermore, any persons exhibiting distress within or on the premises of a health care facility may be directed to the ED for evaluation. Adult patients may arrive in the PED when they are injured or become ill while working or visiting the pediatric hospital, or they may present for care not realizing they are at a pediatric facility. Although several studies have looked at young adult patients who have not transitioned to adult specialty care and are still cared for in pediatric facilities for underlying medical conditions,5–10 there is limited information available on those adult patients not followed by pediatricians or pediatric subspecialists, who may present to the PED. These patients are a potentially high-risk group because they do not have established care within the pediatric health care system and pediatric trained providers may not be as familiar or comfortable with the management of acute conditions in the adult population. The goal of this study was to describe the presentations of adult patients to the PEDs of 2 freestanding tertiary care pediatric hospitals within a large pediatric health care system. Particular attention was given to those adult patients not followed in the pediatric health care system with focus on the reason for seeking care in a pediatric, rather than an adult facility, as well as presenting complaint, triage acuity level, and ultimate disposition from the ED.

From the Departments of *Pediatrics and †Emergency Medicine, Emory University School of Medicine; ‡Pediatric Emergency Medicine, Children's Healthcare of Atlanta; and §Pediatric Emergency Medicine Associates LLC, Atlanta, GA. Disclosure: The authors declare no conflict of interest. Reprints: Wendalyn Little, MD, Division of Pediatric Emergency Medicine, 1645 Tullie Circle NE, Atlanta, GA 30329 (e‐mail: [email protected]). This study was presented in its abstract form at the 2010 Pediatric Academic Societies Meeting. Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 0749-5161

This was a retrospective review of the electronic medical record of the EDs of 2 freestanding tertiary care pediatric hospitals within a pediatric health care system during a 3-year period from 2008 to 2010. Each facility has an ED staffed by both fellowshiptrained PEM physicians and general pediatricians. Pediatric subspecialists are available at both campuses, and each is a designated pediatric trauma center. There are no obstetrical capabilities at either facility, and both are located next to adult hospitals (0.2 miles each). Both facilities routinely see patients up until the 21st birthday; some older patients are followed by pediatric subspecialists past their 21st birthday for chronic conditions present since childhood. The electronic medical record was queried to identify all visits for patients 21 years or older from 2008 to 2010. One author (W.K.L.) reviewed all charts. Patient demographics (age, sex), reason for visit, diagnosis, and treatment details were identified. Reason for visit was categorized as followed by the children's system or a specialist within the system, hospital employee,

Background: Pediatric emergency departments (PEDs) are intended to care for acutely ill and injured children. Adult patients sometimes present to these facilities as well. Some of these are young adults still under the care of pediatric specialists, but older adults and those not under the care of specialists may seek care and may challenge pediatric care providers. Understanding the spectrum of adult illness encountered in the PED may help ensure optimum care for this patient population. Objective: This study aimed to describe the presentations of adult patients in 2 high-volume PEDs of a pediatric health care system. Methods: This is a retrospective review of electronic medical record to identify all visits for patients 21 years or older between 2008 and 2010. Patient demographics, reason for visit, diagnosis, and treatment details were identified. Results: The combined PEDs recorded 417,799 total visits with 1097 patients 21 years or older; 188 of these were still followed by pediatric specialists. For the 907 remaining, the mean age was 36.5.years (range, 21–88 years); 73% were female. Fifty-one percent of the patients were triaged into the highest acuity levels. Fifty-seven percent of the patients were transferred to adult facilities for definitive care. There were no deaths among these patients at either PED, but 2 patients did require intubation and 1 received a period of chest compressions. Reason for presenting to the PED included on-site visitor (45%), mistakenly presented to children's hospital (34%), and hospital employee (21%). The most common presenting complaints were neurologic conditions, trauma/acute injuries, and chest pain. Conclusions: Adult patients in PEDs are rare but have relatively high acuity and often require transfer. Pediatric emergency department clinicians should have adequate, ongoing training to capably assess and stabilize adult patients across a spectrum of illness presentation. Key Words: adult patients, stabilization of emergency condition (Pediatr Emer Care 2014;30: 808–811)

mergency departments (EDs) in freestanding children's hospitals are often staffed by fellowship-trained pediatric emergency medicine (PEM) physicians and general pediatricians. These PEM physicians generally enter the field by way of fellowship training after general pediatrics residency, although some may also enter the field after general emergency medicine residency. The current American Board of Pediatrics and Accreditation Council for Graduate Medical Education requirements for PEM fellowship training of fellows coming from a general pediatrics residency include mandatory experiences in the evaluation and management of acute injury or illness in adult patients because they may be called upon to provide emergency care to adult patients.1

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METHODS

Pediatric Emergency Care • Volume 30, Number 11, November 2014

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Pediatric Emergency Care • Volume 30, Number 11, November 2014

Adult Patients in the PED

on-site hospital visitor, or mistakenly arrived at a pediatric hospital while attempting to access medical care. Both facilities use the Emergency Severity Index (ESI)11 to triage incoming patients; for this study, triage acuity was defined as critical if given an ESI score of 1, high risk for ESI level 2, moderate risk for ESI level 3, and low risk for ESI levels 4 or 5. Visits were grouped by primary chief complaint. The top 3 most common groups were explored in greater depth, as were patients presenting with obstetric complaints because this was considered a particularly high-risk situation because neither facility has obstetric providers or facilities on-site. One-tailed t tests were used for the comparison of continuous variables and Χ2 analysis for the comparison of categorical variables. The institutional review board approved this study and waived the requirement for informed consent.

RESULTS

FIGURE 1. Triage acuity for adults not followed by pediatric specialist.

During the 3-year study period, there were a total of 417,799 visits to the combined PEDs; 1097 were made by patients 21 years or older (2.6/1000 PED visits). In this cohort, 188 visits were made by patients still followed by pediatric specialists for a variety of chronic diseases/conditions including developmental delay from severe cerebral palsy, Down syndrome, and other congenital or acquired neurologic conditions; childhood cancers; and congenital heart disease. A group of 21 patients made 97 of these visits, with frequency ranging from a minimum of 2 to a maximum of 11 visits per patient. Median age at the time of visit for all 188 of these visits was 21.5 years (mean, 22.2 years), and visits were equally split between male (50%) and female (50%) patients. The majority (80%) of these patients were triaged into the highest acuity levels (149 high risk and 3 critical). When the visits made by patients followed in the pediatric health care system were excluded, 909 visits by adult patients not followed in the pediatric health care system were made during the study period. The median age for these patients was 34.3 years (mean, 36.5 years), with a range of 21 to 88 years of age. Compared with the patients followed in the pediatric system, these patients were significantly older (mean, 36.5 vs 22.2 years; P < 0.05) and more likely to be female (73% vs 50%, P < 0.05) (Table 1). Although more than half of these patients were triaged into the highest acuity levels, the proportion was significantly lower than that of the patients followed in the pediatric system (51% vs 80%, P < 0.05) (Fig. 1). For the adult patients not followed in the pediatric system, the reason for visiting the PED (as opposed to an adult facility) included on-site hospital visitor (45%), mistakenly presented to children's hospital (34%), and hospital employee (21%) (Fig. 2). Table 2 details these visits by reason for PED visit. Fifty-seven percent of these adult patients were transferred to adult facilities for definitive care, 33% were discharged home, 5% left before being seen (LWBS), and 5% refused transfer and left against medical advice (AMA) (Fig. 3). There were no deaths among these patients at either PED, but 2 patients did require intubation, and 1 received a period of chest compressions; all 3 of these patients were triaged as critical. Fifteen patients underwent laceration repair, and 1 required chest tube placement.

Forty-eight percent of the patients received at least 1 medication and 22% received intravenous fluids. The 5 most commonly received medication were aspirin (82 patients), followed by oral analgesics (ibuprofen, acetaminophen, or acetaminophen/narcotic combination) (81 patients), intravenous narcotics (76 patients), sublingual nitroglycerin (45 patients), and inhaled β-agonist agents (45 patients). Ten patients received epinephrine injection for allergic reaction. Eight patients received a benzodiazepine for anxiety or agitation, 2 patients received naloxone for suspected opiate overdose, and 2 patients received haloperidol for agitation. The most common presenting complaint group was neurologic symptoms, accounting for 273 patient visits (30% of total 909 visits). This group encompassed a range of clinical presentations including headache, syncope, seizure activity, acute anxiety reactions, mind-altering substance use/abuse, subjective dizziness or near syncope, altered mental status associated with poorly controlled diabetes mellitus, stroke-like symptoms, and manifestations of mental illness. These visits were predominantly made by women (79%), the most common reason for seeking care was on-site visitor (59%), and slightly more than half (56%) were triaged in the 2 highest triage categories. Nine of these visits were noted to be for symptoms occurring after receiving bad news about the status of a loved one in the hospital. An additional 14 visits were made for symptoms associated with alcohol, illicit drug, or medication use. Of these 14 visits, 8 were made by on-site visitors and included 2 parents/guardians of hospitalized children found unresponsive after taking “sleeping pills” in the inpatient area, 1 patient of methadone overdose, and 1 patient found to be under the influence of alcohol; the other on-site visitors showed signs of intoxication/impairment, but no causative substance was specified. The majority of the patients presenting with neurologic complaints (163 visits, 60%) were transferred to another facility, whereas 79 were discharged from the PED, 22 left AMA, and 9 left before being seen. The second most common presenting complaint was trauma or acute injury comprising 188 visits (21% of total 909

TABLE 1. All Adult Patients to the PED Adult Patients (Total, 1097) Followed by pediatric specialist Not followed by pediatric specialist

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n (%)

Age at Visit, Median (Range), y

Female, %

188 (17) 909 (83)

21.5 (21–33) 34.3 (21–88)

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TABLE 2. Adult Patients by Diagnosis Group

n (%); total, 909 Median age, y Female, % Reason for visit, % Employee On-site visitor Wrong hospital Critical or high risk triage category, % Disposition, % Transferred Discharge Left AMA LWBS

Neurologic

Trauma

Chest Pain

273 (30) 36.4 79

188 (21) 32.4 72

129 (14) 38.1 65

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61 (7) 27.3 100

25 59 16 56

15 35 50 20

29 43 28 85

10 67 23 79

60 30 8 2

33 53 5 9

88 4 5 3

92 2 6 -

visits). Again, women were the majority of this group (72%). Thirty-eight of these visits (20%) were triaged as high risk, 92 (49%) as moderate acuity, and 68 (31%) as low acuity (none were triaged as critical). Sixty-four of these trauma-related visits were for evaluation and treatment after motor vehicle collision. Two of these occurred in the parking deck of one of the study site hospitals and an additional pedestrian was struck in the parking deck and had 2 separate ED visits. An additional 50 visits (27% of 188 trauma-related visits) were made for the evaluation after a fall on hospital premises. Twelve of the fall patients were employees, and 37 were hospital visitors. Two of these visits were by pregnant women visiting the hospital who fell within hospital premises; both were transferred for further evaluation in a facility with obstetrical capabilities. For all trauma-related visits, 63 (33%) were transferred, 99 (53%) were discharged from the PED, 16 left without being seen, and 10 left AMA. The third most common presenting complaint was chest pain, comprising 129 visits (14% of the 909 total visits). Again, these visits were more commonly made by women (65% were female). Four were triaged as critical, 106 as high risk, 16 as moderate, and 19 as low acuity. Fifty-five visits (43%) were made by hospital visitors, 38 (29%) by hospital employees, and 36 (28%) by patients attempting to access an adult facility. Eighty patients in this group received aspirin, and 45 received nitroglycerin sublingual for chest pain, whereas 2 patients required adenosine for treatment of cardiac dysrythmias. Seventy-six patients in this group had an electrocardiogram performed. Disposition for the chest pain visits included 114 transfers to adult facilities (88%), 6 left AMA, 5 discharge from the PED, and 4 LWBS. Visits for obstetric related complaints were also examined in greater detail. There were 61 visits (7% of the 909 total visits) for

FIGURE 2. Reason for visit.

Obstetric

primary obstetric related complaints, defined as complaints for vaginal bleeding or discharge or uterine contractions in a pregnant woman. An additional 17 visits for other chief complaints were made by women noted to be pregnant. For the 61 visits, 2 were triaged as critical, 46 as high risk, 12 as moderate acuity, and 1 as low acuity. Reason for visiting the PED included 41 (67%) on-site visitors, 14 (23%) presenting to the wrong facility, and 6 (10%) hospital employees presenting for care. None of the pregnant patients delivered in the PED. Fifty-six (92%) were transferred to facilities with obstetric capabilities, 4 left AMA, and 1 was discharged from the PED.

DISCUSSION This study paints a picture of the visits by adult patients to 2 freestanding PEDs in a large pediatric health care system. Both facilities are in close physical proximity to adult hospitals, which may account for some of the patients inadvertently presenting to the wrong facility while following ED signage. Our results show that a minority (17%) of adult patients presenting to the pediatric facility are young adults who have not yet transitioned to adult care. The patients still followed in the pediatric system were significantly younger and had overall higher acuity than those adult patients not followed in the pediatric system. It would seem that most young adults with chronic conditions do transition at least their ED care to adult facilities, although we have no information about whether they continue to receive ongoing care after making this transition. It also seems that the small number of

FIGURE 3. Disposition. © 2014 Lippincott Williams & Wilkins

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Pediatric Emergency Care • Volume 30, Number 11, November 2014

these adult patients still followed in the pediatric health care system have fairly severe disease burden and may present quite ill to the ED, as evidenced by the high triage acuity. This study is limited by its retrospective nature. Data regarding chief complaint and reason for seeking care were limited to what was recorded in the medical record. One author reviewed all of the charts to provide consistency in interpretation. The study also involves only 1 health care system in a large metropolitan area, and both children's hospitals are in close geographic proximity to adult facilities, which could influence use patterns. This study details the visits by nonestablished adult patients to the PEDs. Hospital visitors and hospital employees made up the majority of visits. Although the overall acuity for these patients was lower than that of the adult patients followed in the pediatric health care system, slightly more than half of the nonestablished adult patients were nevertheless triaged as critical or high risk. It is unclear whether this represents true high acuity presentations, as could be the case with patients presenting from other areas in the hospital where they may have been informally screened by a health care provider or a lack of comfort among pediatric health care providers with adult patients, which could lead to them being assigned with higher triage acuity than they might have been if presenting to an adult facility. Visits for neurologic complaints were frequent, and emergency providers need to be comfortable dealing with the diverse presentations of this patient group. A surprisingly large number of complaints were for acute anxiety reactions and substance use/abuse, particularly among hospital visitors. This might be an area in which hospitals could improve support services for family members dealing with a child's hospitalization and the accompanying stressors and train hospital staff to be vigilant for signs of substance abuse or difficulty coping in parents and other visitors. Visits for trauma-related complaints were also common. A frequently encountered scenario was a parent or other caregiver who had himself or herself been involved in a motor vehicle collision refusing to separate from the child at the accident scene and accompanying a minor child to the pediatric facility then asking to receive care after arrival. It would seem that many of the trauma-related visits were for fairly minor injuries, as more than half were evaluated or treated and discharged from the PED. Another explanation for this finding may be that PEM physicians are more comfortable managing injuries than illness in adult patients. Regardless, it seems imperative that pediatric facilities be comfortable evaluating adult patients after trauma, stabilizing any emergency conditions, and then having procedures in place to transfer patients to adult trauma facilities as needed. Also needed are support mechanisms for these families to help arrange suitable care for pediatric patients while potentially injured adult caregivers receive care. Falls within hospital premises were another common reason for seeking care. Although falls are a known hazard in hospitals and hospitals often have processes in place for preventing patient falls, facilities should continue to be aware of the risk to employees and visitors and use methods such as clear signage and prompt cleaning of wet floors, properly secured rugs, and perhaps targeted resources in place to identify and assist caregivers who may be especially prone to falls such as pregnant mothers, elderly grandparents, and those with limited mobility or sensory impairments.

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Adult Patients in the PED

Chest pain and obstetric complaints may be of particular interest to the PEM provider as cardiac ischemic disease and obstetrics are uncommon in the pediatric population and may represent conditions in which primarily pediatric trained providers do not have much experience in evaluation and management. Training programs in PEM should be aware of the frequency of these complaints and ensure that trainees receive adequate experience to be able to initially evaluate and stabilize these patients. Aspirin and nitroglycerin were 2 of the most commonly administered medications in this study. These medications are not commonly used in pediatric patients, but PEDs may wish to keep an available supply available for adult patients. Moreover, although none of the pregnant adult patients delivered in the PED, possibility of a precipitous delivery should be anticipated and appropriate supplies should be available to deliver the baby and stabilize both the mother and the baby before transfer. Most of the other medications and equipment required by the adult patients in this study are those that should commonly be stocked in PEDs. Given the rather large number of adult patients experiencing anxiety and substance use/abuse symptoms, PEDs should be prepared for the potentially agitated adult patient and have security resources available. Expedient transfer agreements should also be in place to ensure prompt transfer to facilities with the capacity to deal with adult patients presenting with a wide spectrum of complaints and illnesses. REFERENCES 1. ACGME program requirements for graduate medical education in pediatric emergency medicine; 2007. Available at: http://www.acgme.org/ acgmeweb/Portals/0/PFAssets/ProgramRequirements/114_pr707.pdf. Accessed February 10, 2013. 2. Emergency Medical Treatment and Active Labor Act; 2012. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/ index.html. Accessed February 10, 2013. 3. Zibulewski J. The Emergency Medical Treatment and Active Labor Act (EMTALA): what it is and what it means for physicians. Proc (Bayl Univ Med Cent). 2001;14:339–346. 4. Wanerman R. The EMTALA paradox. Ann Emerg Med. 2002;40:464–469. 5. Bourgeois FT, Shannon MW. Adult patient visits to children's hospital emergency departments. Pediatrics. 2003;111(6 pt 1):1268–1272. 6. Hayes A, Reynolds S, Davis AT. Adults in the pediatric emergency department: a fish out of water? Pediatr Emerg Care. 1995;11:170–172. 7. Rhine T, Gittelman M, Timm N. Prevalence and trends of the adult patient population in a pediatric emergency department. Pediatr Emerg Care. 2012;28:141–144. 8. Kibar CR, Borland ML. Too long in the tooth: a descriptive study of adults presenting to a pediatric emergency department. Pediatr Emerg Care. 2006;22:321–333. 9. Fortuna RJ, Halterman JS, Pulcino T, et al. Delayed transition of care: a national study of visits to pediatricians by young adults. Acad Pediatr. 2012;12:405–411. 10. McDonnell WM, Kocolas I, Roosevelt GE, et al. Pediatric emergency department use by adults with chronic pediatric disorders. Arch Pediatr Adolesc Med. 2010;164:572–576. 11. Emergency Severity Index (ESI): a triage tool for emergency department care; 2012. Available at: http://www.ahrq.gov/research/esi/esi1.htm. Accessed February 10, 2013.

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Adult patients in the pediatric emergency department: presentation and disposition.

Pediatric emergency departments (PEDs) are intended to care for acutely ill and injured children. Adult patients sometimes present to these facilities...
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