Figure. Mechanical chest compression device Lifeline ARM on manikin.

group. In the study, the use of the ARM system significantly increased the quality of chest compressions. Further clinical trials are necessary to confirm the findings.

Characterizing Children Presenting to Three freestanding EDs?,??,?

To the Editor,

Lukasz Szarpak, PhD, EMT-P, DPH

Department of Emergency Medicine, Medical University

of Warsaw, Warsaw, Poland Corresponding author at: Department of Emergency Medicine Medical University of Warsaw, 4 Lindleya Str., 02-005 Warsaw, Poland

Tel.: +48 500186225

E-mail address: [email protected]

Krzysztof J. Filipiak, PhD, MD

Department of Cardiology, Medical University

of Warsaw, Warsaw, Poland

Jerzy R. Ladny, PhD, MD Department of Emergency Medicine and Disaster Medical University Bialystok, Bialystok, Poland

Jacek Smereka, PhD, MD Department of Emergency Medical Service Wroclaw Medical University, Wroclaw, Poland

http://dx.doi.org/10.1016/j.ajem.2016.07.057

References

1. Soar J, Nolan JP, Bottiger BW, Perkins GD, Lott C, Carli P, et al. European Resuscitation Council guidelines for resuscitation 2015: section 3. Adult advanced life support. Re- suscitation 2015;95:100-47. http://dx.doi.org/10.1016/j.resuscitation.2015.07.016.
2. Singletary EM, Charlton NP, Epstein JL, Ferguson JD, Jensen JL, MacPherson AI, et al.

   Part 15: first aid: 2015 American Heart Association and American Red Cross guide- lines update for first aid. Circulation 2015;132(18 Suppl. 2):S574-89. http://dx.doi. org/10.1161/CIR.0000000000000269.

   Szarpak L, Truszewski Z, Smereka J, Czyzewski L. Does the use of a chest compression system in children improve the effectiveness of chest compressions? A randomized crossover simulation pilot study. Kardiol Pol 2016. http://dx.doi.org/10.5603/KP. a2016.0107.

3. Kim TH, Hong KJ, Sang Do S, Kim CH, Song SW, Song KJ, et al. Quality between me- chanical compression on reducible stretcher versus Manual compression on standard stretcher in small elevator. Am J Emerg Med 2016;34(8):1604-9. http://dx.doi.org/ 10.1016/j.ajem.2016.05.072 [pii: S0735-6757(16)30205-4].
4. Kurowski A, Szarpak L, Bogdanski L, Zasko P, Czyzewski L. Comparison of the effec- tiveness of cardiopulmonary resuscitation with standard manual chest compressions and the use of TrueCPR and PocketCPR Feedback devices. Kardiol Pol 2015;73(10): 924-30. http://dx.doi.org/10.5603/KP.a2015.0084.

   In recent years, there has been an increase in the number of free- standing emergency departments (FEDs), with over 284 active nation- wide in 2013. As of September 2015, there were 559 FEDs in the United States [1]. Smaller patient loads, greater accessibility, reducED wait times, and higher patient satisfaction suggests the importance of FEDs [2]. One element of FEDs that has not been evaluated is their care of pediatric patients. With the exception of one study in 1992 [3], there have been no published reports characterizing pediatric FED pa- tients. It is important to describe the types of illness and injuries seen in pediatric patients at FEDs. This will allow for proper resources, train- ing, and technology to be incorporated into these facilities, which may improve quality of care.

   This study was a retrospective review evaluating pediatric patients presenting to three FEDs. The hospital’s internal review board approved the study.

   The FEDs in this study are staffed with board eligible or board- certified emergency medicine physicians and are open 24/7, 365 days a year. Unlike urgent care centers in the area, the FEDs offer full labora- tory, x-ray, and CT scans at all times. Ultrasound and magnetic reso- nance imaging are available during the hours of 7 AM to 6 PM Monday through Friday and Saturday mornings.

   The three FEDs are associated with a health system that includes a tertiary care hospital. The hospital serves a metropolitan area that has an estimated population of 703,825 as of July 2014 [4].

   Data was collected using PICIS ED PulseCheck v5.4 for all FED pa- tients under 18 years of age. Conforming to the start of our electronic re- cord system, data was collected from May 13, 2014, to May 31, 2015, for FED 1 and FED 3, and from June 10, 2014, to May 31, 2015, for FED 2. Col- lected variables were patient gender, acuity, age, hourly facility volume, monthly facility volume, and diagnosis.

   Acuity was measured using the Emergency Severity Index , which measures the acuity of cases on a scale from 1 to 5, with 1 having the highest acuity. The admitting diagnoses were characterized by ICD-9 code.

   ? Prior Presentations: International Conference on Emergency Medicine. Poster Pre- sentation, Cape Town South Africa April 2016.

   ?? Funding Sources/Disclosures: None.

   ? Conflicts of Interest: None.

   Table 1

   Gender distribution between FEDs

   	Total volume	FED 1	FED 2	FED 3
   Female	2833	1172	384	1277
   Male	2786	1157	404	1225
   Total	5619	2329	788	2502

   

   Fig. 1. Overall ESI distribution between FEDs for pediatric patients.

   

   Fig. 2. Graph representing patient age at all FEDs.

   Table 2

   age distribution vs Alpern et al

   Age group FEDs Alpern et al

   A value of P b .05 was considered significant for all analyses. Missing data were excluded from calculations of summary statistics. A 1- proportion z-test was used to test claims about a single population pro- portion. Goodness of Fit tests and a Bonferroni correction for multiple comparisons of a series of 2-proportion z-tests were used to determine whether a sample distribution was significantly different from another given distribution. RStudio (v. 0.98.1102) and Microsoft Excel 2010 were used to describe the data.

   A total of 5619 patient encounters were included. FED 1 saw 2329 pediatric patients in its time frame, FED 2 had 788, and FED 3 had 2502.

   Infant 1 to 4	5% 23%	17% 32%	The overall gender distribution of the facilities’ Pediatric cases was nearly even, having no statistically significant difference between the
   5 to 9	23%	22%	proportion of Males and females (P = .265). Gender data are shown
   10 to 14	27%	18%	in Table 1. There were a smaller proportion of males in our study than
   15 to 17	21%	11%	in Alpern et al’s study (P b .0001).

   

   Fig. 3. Graph representing time of arrival for pediatric patients at FED.

   

   Fig. 4. Graph representing total monthly volume of pediatric patients.

   

   Fig. 5. Pie chart representing most common pediatric ICD-9 codes.

   Table 3

   Top individual Diagnosis codes

   Code	Diagnosis	Cases	Percentage
   786.2	Cough	523	9.6
   780.60	Fever	330	6.1
   388.70	Otalgia	289	5.3
   782.1	Rash	261	4.8
   729.5	limb pain	243	4.5
   959.01	Head injury	243	4.5

   Fig. 1 gives the distribution of ESI scores. Being mostly dominated by ESI 3 and 4 patients, pediatric cases are similar to that of the general FED population [5].

   Fig. 2 shows the combined age distribution of the three facilities’ pedi- atric cases. Table 2 compares our sample age distribution to that of Alpern et al. [6]. The sample distribution is significantly different from Alpern’s (P b .0001), and each of our age groups is significantly different than Alpern’s corresponding age group (P =.0023). Our FEDs had significantly older pa- tients than Alpern’s. Older pediatric patients are better able to communi- cate their symptoms, which may lead them to be taken to an FED. It is believed that guardians of younger pediatric patients may be more likely to travel to the pediatric hospital for specialized pediatric care.

   Fig. 3 shows the hourly volume for each of the three facilities’ pedi- atric cases.

   Fig. 4 shows the combined monthly volume for the three facilities’ pediatric cases. The monthly volume of pediatric cases at FEDs was com- parable to typical monthly volumes at adult EDs and FEDs [7].

   Fig. 5 shows the distribution of diagnoses among various groupings of ICD-9 codes. Table 3 shows the top individual diagnosis codes. The types of diagnoses seen at traditional PEDs are similar to those seen at our FEDs. Like Alpern et al’s study, the top diagnoses at FEDs included cough, fever, and ear disorders. One discrepancy is the larger proportion of rashes seen at FEDs. FEDs may attract cases that would not normally be seen at a traditional ED.

   Since FEDs are catering to a growing population, it is important to understand FEDs from several perspectives. Knowing the types of illness and injury that present in the pediatric population to FEDs may help guide resources and improve care.

   Erin L. Simon, DO Cleveland Clinic Akron General Department of Emergency Medicine, Akron, OH

   Corresponding author. Department of Emergency Medicine Cleveland Clinic Akron General, 1 Akron General Ave

   Akron, OH, 44307

   Tel.: +1 330 962 9208; fax: +1 330 761 3416

   E-mail address: [email protected]

   Mitch Kovacs, BS Dave Hayslip, RN, BSN Cleveland Clinic Akron General

   Department of Emergency Medicine, Akron, OH

   Nicholas Jouriles, MD Cleveland Clinic Akron General Department of Emergency Medicine, Akron, OH

   Northeastern Ohio Medical University (NEOMED), Rootstown, OH

   http://dx.doi.org/10.1016/j.ajem.2016.07.060

   References

   Gaumer Z, Stensland J. Emergency department services provided at stand-alone facilities. Lecture presented at MedPAC: advising the congress on Medicare issues, Washington, DC; 2015 [http://www.medpac.gov/documents/september-2015-meeting-presentation- emergency-department-services-provided-at-stand-alone-facilities.pdf?sfvrsn=0].

5. S TerMaat, Freestanding emergency department growth creates backlash. http:// www.amednews.com/article/20130429/business/130429966/4/. [April 29, 2013.

   Accessed July 8, 2015].

   Zimmerman DR, Applebaum D. Quality of pediatric care at a freestanding emergency facility. Pediatr Emerg Care 1992;8(5):265-7 [PMID 1408976].

6. Annual estimates of the resident population: April 1, 2010 to July 1, 2014. Source: U.S. Census Bureau, population division. Retrieved from http://factfinder.census.gov/. [on July 8, 2015].
7. Simon EL, Kovacs M, Jia Z, Hayslip D, Orlik K, Jouriles N. A comparison of Acuity levels between 3 freestanding and a tertiary care ED. Am J Emerg Med 2015;33(4):539-41. http://dx.doi.org/10.1016/j.ajem.2015.01.021.
8. Alpern ER, Clark AE, Alessandrini EA, Gorelick MH, Kittick M, Stanley RM, et al. Recurrent and high-frequency use of the emergency department by pediatric patient. Acad Emerg Med 2014;21(4):365-73 [PMID 24730398].
9. Simon EL, Griffin PL, Jouriles NJ. The impact of two freestanding emergency departments on a tertiary care center. J Emerg Med 2012;43(6):1127-31.

   REDCap: a pediatric ED experience?

   

   To the Editor,

   The dynamic nature of the emergency department (ED) with unpre- dictable patient acuity and volume, coupled with relatively short inter- action times, creates a challenging environment in which to conduct clinical research. One challenge to overcome is data collection. Paper forms are easy to misplace or damage, are subject to data transcription errors [1,2], have a low completion speed, and have no validation checks to prevent incorrect responses or skipping questions [1,2]. Recognizing that paper data collection forms are not conducive to the fast-paced na- ture of the ED-a sentiment shared by the Canadian Association of Emergency Physicians [3]-researchers at our academic, tertiary pediat- ric ED use electronic data collection in real-time using Apple iPads. Treating 70 000 patients each year, our center is one of busiest stand- alone pediatric EDs in Canada; with a highly productive research team [4-7]. As such, we have been able to translate our progressive methods to our national research colleagues. Highlighting some of our unique, novel, and innovative projects, we hope to transfer our research suc- cesses of using iPads and REDCap (Research Electronic Data Capture)

   to conduct live data collection in the ED to a broader audience.

   A number of features make using the iPad and REDCap appealing to conducting research in the ED. The convenient size of the iPads reduces the need to carry research-related forms, it can be disinfected with read- ily available disinfectant wipes [9], and a Wi-Fi connection means that data are entered into the database in real time.

   A Canadian Institutes of Health Research-funded national multicen- ter study prospectively examining concussions in children and youth highlights our process of live data collection [7]. This comprehensive and dense database includes more than 850 unique data fields, more than 4500 variables, and more than 14 000 patient encounters. Given the sheer enormity of the database, paper data collection would be un- manageable. Across 9 sites, research assistants directly collect patient level data from the patients, on the iPads live in the ED. If a patient meets any of the exclusion criteria, a warning is highlighted on the screen to the research assistant. The calculated age variable also permits the automatic administration of age-appropriate questions. The battery of validated symptom inventories posed to a 6-year-old differ than those asked to a 16-year-old [10]; compared to a paper data collection document, REDCap allows for this to occur seamlessly in the ED. More- over, age-appropriate follow-up questionnaires are automatically e- mailed to the families at specific time points, as is a reminder to com- plete incomplete surveys.

   ? Funding sources/disclosures: Dr Plint is supported in part by a Tier II University of Ottawa Research Chair in Pediatric Emergency Medicine.

   ?? Dr. Zemek is supported in part by a Tier II University of Ottawa Research Chair in

   Pediatric concussion.