Legal concerns about the private patient in the pediatric emergency department.
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Child↗
Biomedical subjects
L E Rodewald
Publications and source records attributed to L E Rodewald.
A method for developing and maintaining a powerful but inexpensive computer data base of clinical information about emergency department patients.
We describe a method of creating and maintaining a computer data base containing demographic, diagnostic, procedural, and laboratory data on all emergency department patients. The data base is inexpensive because it avoids redundant data entry; instead, it relies on data already entered into the hospital computers. It is unobtrusive because the ED providers do not have to complete any extra paperwork; data captured on other hospital computers are transferred to the ED data base, making the ED computer a data "parasite." It is powerful because data can be extracted in arbitrarily complex ways using common relational data base software. The data base facilitates administrative, quality improvement, and research tasks for ED managers and researchers. By using standard diagnostic and procedural coding schemes, comparison of patient populations from different EDs can be accomplished. The technologic and financial requirements of this type of data base are within the reach of most EDs.
Computer Communication Networks↗
Missed opportunities for influenza vaccination among children with asthma.
Influenza vaccination is recommended for children with moderate to severe asthma. However, most children with asthma are not vaccinated, in part because many do not make an office visit during the vaccination time period. We studied 247 urban children with asthma to determine the maximum number that could have been vaccinated during a medical visit to a clinic or emergency department. One hundred thirty-nine patients (56%) had at least one visit during the study period. Sixty-five patients (26%) received the influenza vaccination; 74 patients (30%) did not receive the vaccination despite being seen in the clinic or emergency department. One-half of the missed vaccination opportunities at the clinic occurred during nonacute visits. Influenza vaccination rates could be substantially improved by efforts to increase primary care visits during the vaccination time period and to minimize missed vaccination opportunities.
Adolescent↗
The role of the emergency department in primary care.
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Child, Preschool↗
Improving influenza vaccination rates in children with asthma: a test of a computerized reminder system and an analysis of factors predicting vaccination compliance.
Fewer than 10% of children with moderate or severe asthma receive an annual influenza vaccination despite their heightened susceptibility to severe infections and recommendations by the American Academy of Pediatrics and the Immunization Practices Advisory Committee that all such children be vaccinated annually. Patient, provider, and system factors leading to this poor vaccination rate are not well understood. This study tested the effectiveness of a computerized reminder system in improving influenza vaccination rates in children with asthma and examined patient barriers to vaccination at one pediatric clinic in an urban teaching hospital. A computer database identified 124 children with moderate or severe asthma. Patients were randomly assigned either to study group (n = 63), who were sent a personalized letter reminder about the need for an influenza vaccination, or to a control group (n = 61), who received no reminder. Study group mothers were interviewed 2 months after the letter was sent to assess factors associated with receipt of vaccination, including demographic features, parental worry about asthma and vaccine side effects, the four dimensions of the Health Belief Model, and health locus of control beliefs. Nineteen study group patients (30%) received an influenza vaccination, compared with only 4 control patients (7%) (P < .01). Forty-three mothers of children in the study group were interviewed; 14 (33%) of these children had received the vaccination. Of the characteristics investigated, two significantly correlated with vaccination compliance: high levels of parental worry about asthma (positively correlated: odds ratio = 23.3, P < .01) and high levels of parental worry about vaccine side effects (negatively correlated: odds ratio = 0.087, P = .025).(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
Relevance of common tests of cerebrospinal fluid in screening for bacterial meningitis.
This study tests the hypothesis that if cerebrospinal fluid (CSF) has a nucleated blood cell count (NucBC) of less than 6/mm3, CSF tests other than bacterial culture need not be performed to exclude the diagnosis of bacterial meningitis in patients not receiving antimicrobial agents. The results of tests performed on the first specimen of CSF obtained for a given hospital visit from children younger than 3 years of age, exclusive of newborn infants admitted to the hospital on their date of birth, were analyzed. Of 3356 CSF specimens evaluated, 122 were from patients with bacterial meningitis; 460 specimens were analyzed separately because the erythrocyte count was greater than 1000/mm3. A negative CSF screening test result was defined as a CSF NucBC less than 6/mm3. In facilitating the diagnosis of bacterial meningitis, this screening test had a sensitivity of 98.4%, a specificity of 75.2%, and a negative predictive value of 99.9%. The other CSF tests varied widely in screening effectiveness: a Gram-stained smear had a sensitivity of 53% and a specificity of 97%. Receiver operating characteristic curve analysis was used to assess the screening relevance of CSF tests. The CSF NucBC and CSF segmented NucBC performed indistinguishably and superiorly compared with the CSF protein or glucose concentration and the ratio of CSF glucose to serum glucose concentration. Logistic regression analysis showed that the NucBC alone is superior to any combination of the other CSF tests. In a prospective study of 215 children younger than 3 years of age undergoing a lumbar puncture in our emergency department, 85% had empiric criteria identifying them as appropriate for an abbreviated CSF evaluation. The CSF NucBC was less than 6/mm3 in 70% of the 181 patients who would have been eligible for an abbreviated CSF evaluation. These data suggest that a strategy for the sequential testing of CSF could be adopted that would exclude unnecessary determinations and thereby save time, effort, and health care dollars.
Blood Glucose↗
Two methods for developing and maintaining a database of clinical information on outpatient encounters: a comparison of process, costs, and benefits.
We describe and compare two relational databases that capture and store clinical information about ambulatory patients. One system is based on an encounter form; the other is a "parasite" that passively collects data from other hospital computers. We compare the system development processes, costs, and benefits of these two computerization strategies.
Ambulatory Care Information Systems↗
Deuterium oxide as a tracer for measurement of compliance in pediatric clinical drug trials.
We tested the hypothesis that a deuterium oxide (D2O) tracer could discriminate among patterns of clinically significant, imperfect compliance during drug trials. A model was developed to predict deuterium concentration during multiple dose regimens. After developing a regression equation to predict one of the model parameters for children, we selected healthy children (N = 20) at random to receive one of five 10-day D2O regimens. Five urine samples were obtained from each child during 15 days and analyzed for deuterium level by mass spectrometry. Each child's height, weight, age, and the first four urinary deuterium levels were used to estimate the amount and timing of deuterium administration. These estimates were compared with the five regimens to determine the closest match between estimate and regimen. The closest matching regimen was the regimen actually administered to 19 (95%) of the 20 children. Two of these children had D2O administration estimates that could be confused with another regimen. The correlation between the model's predicted levels and the measured levels of all urine samples was 0.96. We conclude that a D2O tracer shows excellent promise as a quantitative method of assessing compliance with liquid medications under specified conditions.
Child↗
ROC curves for classification trees.
A common problem in medical diagnosis is to combine information from several tests or patient characteristics into a decision rule to distinguish diseased from healthy patients. Among the statistical procedures proposed to solve this problem, recursive partitioning is appealing for the easily-used and intuitive nature of the rules it produces. The rules have the form of classification trees, in which each node of the tree represents a simple question about one of the predictor variables, and the branch taken depends on the answer. The authors consider the role of misclassification costs in developing classification trees. By varying the ratio of costs assigned to false negatives and false positives, a series of classification trees are generated, each optimal for some range of cost ratios, and each with a different sensitivity and specificity. The set of sensitivity-specificity combinations define a curve that can be used like an ROC curve.
Child, Preschool↗
Adequacy of well-child care and immunization.
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Child Health Services↗