282 Abstracts

, EARLY PEDIATRIC EMERGENCY DEPARTMENTRETURNVISITS:APROSPECTIVEPATIENT-CENTRICASSESSMENT. Ali AB, Place R, Howell J, et al. Clin Pediatr(Phila) 2012;51:651–8.

The objective of this study was to determine why caregiversof children returned to the Emergency Department (ED) within72 h of their initial visit. Data were from a single, suburban, 24-hpediatric ED at a tertiary-care, level I trauma center with an an-nual census of approximately 30,000. Participants were eligibleif they had returned to the ED with a prior visit within theprevious 72 h. Data collection was performed by a trained inter-viewer during 4 non-consecutive months and included demo-graphics as well as satisfaction with both physician at initialED visit and discharge instructions. Analysis included descrip-tive statistics using chi-squared and Mann-Whitney U tests.

During the 4months, 2.8% of patients (246 of 8742) returnedwithin 72 h of their initial visit. Of these, 124 were surveyed.Compared to those who were not surveyed, those surveyedwere more likely to have been diagnosed with fever, trauma,or seizure disorders; there were no observed differences inage, sex, patient acuity, or type of insurance. Among thosesurveyed, participants were excluded for scheduled return visits(n = 17) and returns for complaints unrelated to initial visit(n = 14), leaving 93 individuals for analysis. Of these,87 (94%) were satisfied with both the ED physician on the initialvisit and the discharge instructions, and 50 (53%) had contactedtheir primary care physician (PCP) before returning the ED.Among those who had contacted their PCP, 14 (28%) were un-able to schedule an appointment, 32 (64%) were advised to re-turn to the ED, and 3 (6%) were evaluated by their PCP and toldto return to the ED the same day. Of those returning, 29 (30%)were admitted to the hospital for progression of illness.

In summary, caregivers of children who return to the pediat-ric ED within 72 h tend to be satisfied with both their initial EDphysician visit and the discharge instructions received. How-ever, nearly half had not contacted their PCP before returningand, of those who had contacted their PCP, the majority were ei-ther unable to make an appointment or instructed to return to EDfor reevaluation.

[Lauren M. Abbate, MD, PHDDenver Health Medical Center, Denver, CO]

Comment: This study describes from a caregiver perspectivewhy children return to the pediatric EDwithin 72 h and suggeststhat return visits are not related to dissatisfaction with the initialED physician or discharge instructions, but rather, are related toeither appropriate return for progression of illness or for poorPCP follow-up. Although this study has methodological limita-tions, including a small, convenience sample, it suggests thatimprovement in PCP follow-up may help reduce return visitsto the ED within 72 h, and further studies should aim to developmethods to do so.

, DURATION OF RESUSCITATION EFFORTS ANDSURVIVAL AFTER IN-HOSPITAL CARDIAC ARREST:AN OBSERVATIONAL STUDY. Goldberger ZD, Chan PS,Berg RA, et al. Lancet 2012;380:1473–81.

In-hospital cardiac arrest occurs in one to five of every 1000hospital admissions. Despite this relative frequency, little

evidence exists to guide the length of the resuscitation of thesepatients, which has lead to significant differences between hos-pitals. This observational study examined the variation in thelength of resuscitation across 435 U.S. hospitals and whetherlonger resuscitations correlated with higher rates of survival tohospital discharge.

In this study, 64,339 patients with in-hospital cardiac arrestwere identified over an 8-year period from the Get With TheGuidelines – Resuscitation registry. The authors separatedeach institution into four quartiles based on the median lengthof resuscitation. Primary outcomes were the return of spontane-ous circulation and survival to hospital discharge. One second-ary outcome was neurologic survival to hospital discharge asdefined by cerebral performance category scores.

Large variation was noted in the length of resuscitationamong the institutions studied, with the shortest quartiledemonstrating a median of 16-min resuscitations, and thelongest a median of 25 min. Hospitals with the longest resus-citation lengths did have a higher rate of survival to hospitaldischarge with 16.2% of patients surviving to discharge in thelongest quartile, compared to 14.5% of patients in the short-est quartile. This difference in survival was most pronouncedin patients with pulseless electrical activity or asystole.However, no difference was noted in survival to hospitaldischarge with a favorable neurologic status across the differ-ent quartiles (adjusted risk ratio 1.0, 95% confidence interval0.95–1.06).

[Michael Ruygrok, MD

Denver Health Medical Center, Denver, CO]

Comment: Although the authors noted improved rates ofreturn of spontaneous circulation and survival to hospital dis-charge with longer resuscitations, there was no difference inpatients surviving to hospital discharge with good neurologicfunction. Therefore, prolonged resuscitations do not increasethe number of patients leaving the hospital neurologically intact,which may question the utility of prolonged resuscitation in thesetting of in-hospital cardiac arrest.

, STRESS-INDUCED HYPERGLYCEMIA, NOT DI-ABETIC HYPERGLYCEMIA, IS ASSOCIATED WITHHIGHER MORTALITY IN TRAUMA. Kerby JD, GriffinRL, MacLennan P, et al. Ann Surg 2012;256:446–52.

Hyperglycemia is a normal physiologic response to stress,but may also be due to underlying diabetes mellitus. Regard-less of the etiology, hyperglycemia has been shown to ad-versely affect outcomes in a variety of patient populations.Whereas prior studies have shown higher mortality rates inhyperglycemic trauma patients, no study has differentiatedbetween stress-induced hyperglycemia (SIH) and diabetesmellitus (DM).

This prospective observational study included 5117 traumapatients at a single center to determine whether SIH or DMaffected overall mortality rates. Patients with a normal hemo-globin A1C and a blood sugar > 200 on admission were identi-fied as SIH, and patients with a hemoglobin A1C > 6.5% andhyperglycemia were identified as diabetics.

After adjustment for age, sex, injury mechanism, and injuryseverity score, patients with SIH had a relative risk (RR) of