OBJECTIVE: Adverse drug events (ADEs) are a common complication of medical care, but few pediatric data are available describing the frequency or epidemiology of these events. We estimated the national incidence of pediatric ADEs requiring medical treatment, described the pediatric population seeking care for ADEs, and characterized the events in terms of patient symptoms and medications implicated. METHODS: Data were obtained from the National Center for Health Statistics, which collects information on patient visits to outpatient clinics and emergency departments throughout the United States. We analyzed data for children 0 to 18 years of age seeking medical treatment for an ADE between 1995 and 2005. RESULTS: The mean annual number of ADE-related visits was 585922 (95% confidence interval [CI]: 503687-668156) of which 78% occurred in outpatient clinics and 12% occurred in emergency departments. Children 0 to 4 years of age had the highest incidence of ADE-related visits, accounting for 43.2% (95% CI: 35.6%-51.2%) of visits. The most common symptom manifestations were dermatologic conditions (45.4% [95% CI: 36.9%-54.1%]) and gastrointestinal symptoms (16.5% [95% CI: 11.1%-23.8%]). The medication classes most frequently implicated in an ADE were antimicrobial agents (27.5% [95% CI: 21.5%-34.5%]), central nervous system agents (6.5% [95% CI: 4.0%-10.5%]), and hormones (6.1% [95% CI: 3.1%-11.6%]). While ADEs related to antimicrobial agents were most common among children 0 to 4 years old and decreased in frequency among older children, ADEs resulting from central nervous system agents and hormones increased in frequency among children 5 to 11 and 12 to 18 years old. CONCLUSIONS: ADEs result in a substantial number of health care visits, particularly in outpatient clinics. The incidence of ADEs and medications implicated vary by age, indicating that age-specific approaches for monitoring and preventing ADEs may be most effective.

STUDY OBJECTIVE: The epidemiology of children who present to the emergency department (ED) and leave without being seen has not been well characterized. We evaluate rates and secular trends of children who leave without being seen, identify factors associated with pediatric leave without being seen cases, and determine whether there are differences in leaving patterns between children and adults seeking emergency care. METHODS: Data were obtained from the National Hospital Ambulatory Medical Care Survey, which collects information on patient visits to EDs throughout the United States. We examined data for children (less than or equal to 18 years of age) and adults who presented to EDs during the 6-year period ending in 2005. RESULTS: During the study period, there were an estimated 11,848,351 leave without being seen visits nationally, accounting for 1.79% of all ED visits. The prevalence of leaving without being seen was 2.46% (95% confidence interval [CI] 1.71% to 3.55%) for pediatric patients presenting to pediatric EDs, 1.86% (95% CI 1.65% to 2.10%) for pediatric patients presenting to general EDs, and 1.73% (95% CI 1.57% to 1.91%) for adults presenting to general EDs. The leave without being seen rates did not increase significantly during the study period. Factors associated with leave without being seen visits included hospital urban location, self-pay insurance status, and less acute triage level for children and adults, as well as race/ethnicity and arrival time for adult patients. CONCLUSION: In this national sample of patients, leave without being seen rates were similar for pediatric and adult patients and did not increase during the 6-year study period, although some variation in rates was observed for specific patient and ED characteristics. These national estimates provide an important reference for institutions to assess their ED performance.

BACKGROUND: Personally controlled health records (PCHRs) are accessible over the Internet and allow individuals to maintain and manage a secure copy of their medical data. These records provide a new opportunity to provide customized health recommendations to individuals based on their record content. Health promotion programs using PCHRs can potentially be used in a variety of settings and target a large range of health issues. OBJECTIVES: The aim was to assess the value of a PCHR in an employee health promotion program for improving knowledge, beliefs, and behavior around influenza prevention. METHODS: We evaluated a PCHR-based employee health promotion program using a randomized controlled trial design. Employees at Hewlett Packard work sites who reported reliable Internet access and email use at least once every 2 days were recruited for participation. PCHRs were provided to all participants for survey administration, and tailored, targeted health messages on influenza illness and prevention were delivered to participants in the intervention group. Participants in the control group received messages addressing cardiovascular health and sun protection. The main outcome measure was improvement in knowledge, beliefs, and behavior around influenza prevention. Secondary outcomes were influenza vaccine rates among household members, the impact of cardiovascular health and sun protection messages on the control group, and the usability and utility of the PCHR-based program for employees. RESULTS: The intervention did not have a statistically significant effect on the influenza knowledge elements we assessed but did impact certain beliefs surrounding influenza. Participants in the intervention group were more likely to believe that the influenza vaccine was effective (OR = 5.6; 95% CI = 1.7-18.5), that there were actions they could take to prevent the flu (OR = 3.2; 95% CI = 1.1-9.2), and that the influenza vaccine was unlikely to cause a severe reaction (OR = 4.4; 95% CI = 1.3-15.3). Immunization rates did not differ between the intervention and control groups. However, participants in the intervention group were more likely to stay home during an infectious respiratory illness compared with participants in the control group (39% [16/41] vs 14% [5/35], respectively; P = .02). The program also succeeded in improving recognition of the signs of heart attack and stroke among participants in the control group. Overall, 78% of participants rated the PCHR as "extremely/very" easy to use, and 73% responded that they would be "extremely/very" likely to participate again in a PCHR-based health promotion system such as this one. CONCLUSIONS: With a small sample size, this study identified a modest impact of a PCHR-based employee health program on influenza prevention and control. Employees found the PCHR acceptable and easy to use, suggesting that it should be explored as a common medium for health promotion in the workplace. TRIAL REGISTRATION: ClinicalTrials.gov NCT00142077.

OBJECTIVE: We examine the pediatric emergency department (ED) population and their clinical course in pediatric versus general EDs and identify potential factors contributing to differences in performance metrics between the 2 ED settings. METHODS: This was a retrospective analysis of pediatric visits to nationally representative EDs participating in the National Hospital Ambulatory Medical Care Survey from 1995 to 2002. Differences between pediatric and general EDs were examined in terms of patient characteristics and clinical course. RESULTS: Pediatric EDs treated more children with medical problems than general EDs, which treated more children with injuries. Visits by children to pediatric EDs were associated with longer wait times to see a physician (median, 40 vs. 25 minutes; P 0.001) and longer stays in the ED (median, 130 vs. 98 minutes; P = 0.006). In multivariate analysis, the type of ED treating a pediatric patient was a significant determinant of wait time (percent change for pediatric EDs, 23.1; 95% confidence interval [CI], 3.4-46.6), length of stay (percent change for pediatric EDs, 23.0; 95% CI, 5.1-43.9), and rate of discharge (odds ratio for pediatric EDs, 0.75; 95% CI 0.61-0.92). Children in pediatric EDs seemed to be sicker than those in general EDs. CONCLUSIONS: These data provide the first glimpse of health care delivery to children seen in EDs nationally. Our findings indicate that significant differences exist between pediatric visits to pediatric and general EDs. These findings may be useful in establishing performance metrics for the care of ill and injured children in both pediatric and general EDs.

OBJECTIVE: To determine the accuracy of self-reported information from patients and families for use in a disease surveillance system. DESIGN: Patients and their parents presenting to the emergency department (ED) waiting room of an urban, tertiary care children's hospital were asked to use a Self-Report Tool, which consisted of a questionnaire asking questions related to the subjects' current illness. MEASUREMENTS: The sensitivity and specificity of three data sources for assigning patients to disease categories was measured: the ED chief complaint, physician diagnostic coding, and the completed Self-Report Tool. The gold standard metric for comparison was a medical record abstraction. RESULTS: A total of 936 subjects were enrolled. Compared to ED chief complaints, the Self-Report Tool was more than twice as sensitive in identifying respiratory illnesses (Rate ratio [RR]: 2.10, 95% confidence interval [CI] 1.81-2.44), and dermatological problems (RR: 2.23, 95% CI 1.56-3.17), as well as significantly more sensitive in detecting fever (RR: 1.90, 95% CI 1.67-2.17), gastrointestinal problems (RR: 1.10, 95% CI 1.00-1.20), and injuries (RR: 1.16, 95% CI 1.08-1.24). Sensitivities were also significantly higher when the Self-Report Tool performance was compared to diagnostic codes, with a sensitivity rate ratio of 4.42 (95% CI 3.45-5.68) for fever, 1.70 (95% CI 1.49-1.93) for respiratory problems, 1.15 (95% CI 1.04-1.27) for gastrointestinal problems, 2.02 (95% CI 1.42-2.87) for dermatologic problems, and 1.06 (95% CI 1.01-1.11) for injuries. CONCLUSIONS: Disease category assignment based on patient-reported information was significantly more sensitive in correctly identifying a disease category than data currently used by national and regional disease surveillance systems.

BACKGROUND: The Centers for Disease Control and Prevention is incorporating laboratory data into real-time surveillance systems. When normal patterns of laboratory test orders and results are modeled, aberrations can be detected. Because many test orders are available electronically well before results, atypical patterns of test ordering may signal outbreaks. OBJECTIVES: The authors sought to characterize baseline patterns in the ordering and early results of lumbar punctures, motivated by the possibility of using these data for real-time surveillance for early detection of meningitis or encephalitis outbreaks. METHODS: Retrospective cohorts of pediatric emergency department patients at a single hospital (1993-2003) and from the National Hospital and Ambulatory Medical Care Survey (1992-2000) were used for analysis. RESULTS: Test ordering exhibits seasonal patterns, with monthly peaks in January and August (p 0.0001). For the hospital cohort, the rate of cerebrospinal fluid pleocytosis exhibits seasonal patterns (p 0.0001), with a peak from August to October. This is strongly associated with the rate and pattern of clinical neurologic disease (p 0.0001). A long-term secular decline in daily test ordering is evident, dropping from 5.3 to 2.9 in the hospital sample, and from 371.8 to 185.3 in the national sample (p 0.001). The long-term rate of pleocytosis has declined (p 0.0001), though the yield of testing for pleocytosis has improved (p = 0.0104). CONCLUSIONS: Laboratory test patterns correspond with those of clinical disease and are a promising source of surveillance data. Using such data for real-time monitoring requires specific adjustments for patient age, periodicities, and secular trends.

BACKGROUND: Influenza and other winter respiratory viruses cause substantial morbidity among children. Previous estimates of the burden of illness of these viruses have neglected to include the emergency department, where a large number of patients seek acute care for respiratory illnesses. This study provides city- and statewide population estimates of the burden of illness attributable to respiratory viruses for children receiving emergency department-based care for respiratory infections during the winter months. METHODS: The number of patients or = 7 years of age presenting to the emergency department of an urban tertiary care pediatric hospital with acute respiratory infections was estimated by using a classifier based on presenting complaints. The rates of specific viral infections in this population were estimated by using the rates of positivity for respiratory syncytial virus, influenza virus, parainfluenza virus, adenovirus, and enterovirus. Local emergency department market share and US Census data enabled determination of the rates of emergency department visits in the Boston, Massachusetts, area and in Massachusetts. RESULTS: During the 11-year study period, the mean yearly number of patients or = 7 years of age presenting to the study emergency department during the winter season was 17397. On the basis of the respiratory classifier, the mean number of patients with an acute respiratory infection was 6923, or 398 per 1000 emergency department visits. In the city population, the mean number of emergency department visits for acute respiratory infections was 17906, which is equivalent to 113.9 per 1000 children residing in the city, and in the state population the mean number was 61529, or 94.5 per 1000 children residing in the state. At the state level, 23114 of the visits were for respiratory syncytial virus, 5650 for influenza, 1751 for parainfluenza virus, 2848 for adenovirus, and 798 for enterovirus. For patients 6 to 23 months of age in the state population, there were 19860 emergency department visits for acute respiratory infections, or 168 per 1000 children in this age group, with 6235 visits resulting from respiratory syncytial virus and 2112 resulting from influenza. CONCLUSION: There is a high incidence of emergency department visits for infectious respiratory illnesses among children. This important component of health care use should be included in estimates of the burden of illness attributable to influenza and other winter respiratory viruses.

STUDY OBJECTIVE: A key public health question is whether syndromic surveillance data provide early warning of infectious outbreaks. One cause for skepticism is that biological correlates of the administrative and clinical data used in these systems have not been rigorously assessed. This study measures the value of respiratory data currently used in syndromic surveillance systems to detect respiratory infections by comparing it against criterion standard viral testing within a pediatric population. METHODS: We conducted a longitudinal study with prospective validation in the emergency department (ED) of a tertiary care children's hospital. Children aged 7 years or younger who presented with a respiratory syndrome or who were tested for respiratory syncytial virus (RSV), influenza virus, parainfluenza virus, adenovirus, or enterovirus between January 1993 and June 2004 were included. We assessed the predictive ability of the viral tests by fitting generalized linear models to respiratory syndrome counts. RESULTS: Of 582,635 patient visits, 89,432 (15.4%) were for respiratory syndromes, and of these, 7,206 (8.1%) patients were tested for the viruses of interest. RSV was significantly related to respiratory syndrome counts (adjusted rate ratio [RR] 1.33; 95% confidence interval [CI] 1.04 to 1.71). In multivariate models including all viruses tested, influenza virus was also a significant predictor of respiratory syndrome counts (RR 1.47; 95% CI 1.03 to 2.10). This model accounted for 81.6% of the observed variability in respiratory syndrome counts. CONCLUSION: Respiratory syndromic surveillance data strongly correlate with virologic test results in a pediatric population, providing evidence of the biologic validity of such surveillance systems. Real-time outbreak detection systems relying on syndromic data may be an important adjunct to the current set of public health systems for the detection and surveillance of respiratory infections.

OBJECTIVE: To determine whether wait times for children treated in emergency departments (EDs) nationally are associated with patient race/ethnicity. METHODS: Data were obtained from the National Hospital Ambulatory Medical Care Survey, which collects information on patient visits to EDs throughout the United States. We examined data for patients or =15 years of age who presented to EDs during the 4-year period of 1997-2000. Sample weights were applied to the identified patient records to yield national estimates. For the purposes of this study, race/ethnicity was analyzed for 3 major groups, ie, non-Hispanic white (NHW), non-Hispanic black (NHB), and Hispanic white (HW). RESULTS: During the 4-year study period, 20633 patient visits were surveyed, representing a national sample of 92.9 million children or =15 years of age. The race/ethnicity distribution included 9019 NHW children (59.5%), 3910 NHB children (23.9%), and 2991 HW children (16.6%). The wait time for all groups was 43.6 +/- 1.7 minutes (mean +/- SEM). There were significant unadjusted intergroup differences in wait times (38.5 +/- 1.6 minutes, 48.7 +/- 0.5 minutes, and 54.5 +/- 0.1 minutes for NHW, NHB, and HW children, respectively). Visit immediacy (triage status), when reported, was categorized as 15 minutes for 2203 children (17.1%), 15 to 60 minutes for 5324 (41.4%), 1 to 2 hours for 3010 (25.1%), and >2 to 24 hours for 1910 (16.4%). There were significant unadjusted differences in triage status according to race, with 14.6% of NHW patients being placed in the >2-hour immediacy range, compared with 18.8% of NHB patients and 20.0% of HW patients. In a linear regression analysis with logarithmically transformed wait time as a dependent variable and with adjustment for potential confounders, including hospital location, geographic region, and payer status, both NHB and HW patients waited longer than NHW patients, although the results were statistically significant only for HW patients. CONCLUSIONS: These nationally representative data suggest that children who come to EDs have wait times that vary according to race/ethnicity. There are several potential explanations for this observation, including discrimination, cultural incompetence, language barriers, and other social factors. These data and similar data from the National Hospital Ambulatory Medical Care Survey are useful in identifying nonclinical influences on the delivery of pediatric emergency care.

BACKGROUND: Adults frequently seek medical services in children's hospital emergency departments (CHEDs), and are required to be admitted to CHEDs under the provisions of the Emergency Medical Transfer and Active Labor Act (EMTALA), which requires medical evaluation and stabilization of every patient who presents to an emergency department. In recent years visits by adults to CHEDs appear to have increased. OBJECTIVE: There were 3 objectives to the current study: 1) to examine secular trends in the number of adult patients visiting CHEDs, 2) to determine if perceived increases are related to the implementation of EMTALA, and 3) to examine the characteristics, evaluation, and disposition of adult patients presenting for first-time visits to a CHED. METHODS: A database of all visits to an urban CHED between 1992 and 2002 was queried to collect information on adult patients (22 years or older). New adult patients were identified based on the assignment of new medical record numbers. The medical records of all adult patients presenting during the 1-year interval before and after the institution's full implementation of EMTALA were reviewed and relevant data collected. RESULTS: Over the study period, there were 501,033 patient visits to the CHED. Of these, 5512 (1.1%) were by adult patients, which included 536 (9.7%) new adult patients. Using the chi(2), test we found a significant increase in the total number of adult visits and the number of new adult visits, particularly after the implementation of EMTALA. The mean age of the new adult patients was 34.9 +/- 11.9 years. Their most frequent chief complaints were injuries (24.4%), cardiac-related problems (7.6%), and syncope (6.7%). A total of 427 (79.7%) of the new adult patients were treated and released, 81 (15.1%) were transferred to an outside hospital for additional care, and 15 (2.8%) were admitted to our hospital. There were no significant differences between the new adult populations in 1997 and 1999. Comparing new and established adult populations in 1999, the population of new adults was significantly older (28.1 +/- 6.8 vs 34.9 +/- 11.9 years) and more likely to present with injuries or syncopal episodes. Among the total cohort of new adult patients in the study, chest pain also occurred at a significantly higher rate compared with established adults (6.7% vs 3.8%). CONCLUSIONS: Adult visits to CHEDs appear to be increasing in frequency in association with the implementation of EMTALA regulations. It is therefore essential that physicians staffing CHEDs be properly trained in the stabilization of common adult medical emergencies. We recommend that the language of EMTALA be revised to allow adult patients with nonemergent problems to be directly referred to adult emergency departments, which are more appropriate than CHEDs.