Characteristics of pediatric emergency department frequent visitors and their risk of a return visit: A large observational study using electronic health record data

Abstract

Background Among pediatric emergency department (ED) visits, a subgroup of children repeatedly visits the ED, making them frequent visitors (FVs). The aim of this study is to get insight into the group of pediatric ED FVs and to determine risk factors associated with a revisit. Methods and findings Data of all children aged 0–18 years visiting the ED of a university hospital in the Netherlands between 2017 and 2020 were included in this observational study based on routine data extraction. Children with 4 or more ED visits within 365 days were classified as FVs. Descriptive analysis of the study cohort at patient- and visit-level were performed. Risk factors for a recurrent ED visit were determined using a Prentice Williams and Peterson gap time cox-based model. Our study population of 10,209 children with 16,397 ED visits contained 500 FVs (4.9%) accounting for 3,481 visits (21.2%). At patient-level, FVs were younger and more often suffered from chronic diseases (CDs). At visit-level, frequent visits were more often initiated by self-referral and were more often related to medical problems (compared to trauma’s). Overall, FVs presented at the ED more often because of an infection (41.3%) compared to non-FVs (27.4%), either associated or not with the body system affected by the CD. We identified the presence of a comorbidity (non-complex CD HR 1.66; 1.52–1.81 and complex CD HR 2.00; 1.84–2.16) as determinants with the highest hazard for a return visit. Conclusion Pediatric ED FVs are a small group of children but account for a large amount of the total ED visits. FVs are younger patients, suffering from (complex) comorbidities and present more often with infectious conditions compared to non-FVs. Healthcare pathways, including safety-netting strategies for acute manifestations from their comorbidity, or for infectious conditions in general may contribute to support parents and redirect some patients from the ED.

Paediatric frequent use of emergency medical services: a systematic review

“…All four EMS studies23–26 were conducted in single EMS. Four ED studies30 31 33 34 were conducted in a single site, and the other four ED studies27–29 32 ranged from 3 sites29 to 22 sites,27 with one conducted in an unreported number of sites across two Canadian provinces 32 Table 1. summarises the study characteristics of all 12 included studies.…”

“…Two studies, both of which included EMS callers of any age across the full sample, provided no definition of paediatric patients 24 26. The most common definitions, both used in three studies, were <18 years27 32 33 and <19 years 30 31 34. The lowest age definition of paediatric users was <15 years 28.…”

“…Four studies [23][24][25][26] were conducted in EMS settings, of which three [24][25][26] used all EMS contacts via telephone and one [23] examined ED conveyance. Eight studies [27][28][29][30][31][32][33][34] were conducted using ED data with arrivals via EMS or ambulance as inclusion criterion. All twelve studies were conducted retrospectively and none followed an interventional design.…”

“…Two studies identified that frequent use of ED was associated with decreased EMS use; Alpern et al, [27] a multi-centre study in the United States with 22 sites, found that users without recurrent visits arrived via EMS in 10% of visits, as opposed to 5-6% for recurrent visits. Vrijlandt et al, [34] a single-centre study in The Netherlands, found that 11.7% of frequent users arrived via ambulance compared to 20.7% of non-frequent attenders, meaning that arrival via ambulance reduced the hazard of returning. Two single-centre studies conducted in United States [31] and Canada [32] found no difference in ambulance use between frequent and non-frequent users.…”

Febrile children with comorbidities at the emergency department — a multicentre observational study

“…There is an important health paradox regarding children with comorbidities attending the emergency department (ED). On one hand, these children form an increasing group [1]; constitute a large part of the so-called "ED frequent flyers" [2,3]; have an increased risk for invasive bacterial infections (sepsis/meningitis) as well as serious bacterial infections, such as urinary tract infections, pneumonia, or bone and joint infections [4][5][6][7]; and use a larger amount of ED and hospital resources [8,9], yet on the other hand are very often excluded from studies [10][11][12][13]. When research does include children with comorbidities, it usually focuses on specific types of comorbidities, such as febrile neutropenia [14].…”