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Jay Pershad

Publications and source records attributed to Jay Pershad.

13 recordsLinked to original sources
PubMed2006

Cost-effectiveness analysis of sedation and analgesia regimens during fracture manipulation in the pediatric emergency department.

OBJECTIVE: To conduct a cost-effectiveness analysis, from a hospital's perspective, of 4 procedural sedation and analgesia (PSA) regimens to facilitate forearm fracture manipulation in the pediatric emergency department (ED): deep sedation with ketamine/midazolam (K/M) administration, propofol/fentanyl administration, fentanyl/midazolam (F/M) administration, and axillary block. DESIGN/METHODS: We constructed a decision analytic model using relevant probabilities from published studies of pediatric patients who underwent fracture manipulation in the EDs. Total costs were calculated by assessing ED resource utilization associated with uncomplicated PSA and with PSA complicated by adverse events. Costs of consumable equipment were considered to be fixed. Total sedation time, personnel time, and drug costs were considered variable. We assumed that all PSA regimens provided effective relief from procedural distress. Failure rates for axillary block were estimated based on reports in the literature. When patients experienced emesis, recovery agitation, respiratory depression, lidocaine toxicity, or regional block failure, we assumed that the patients would require 1 additional hour of ED stay. Sensitivity analyses of all key variables in the model were performed to identify those that may result in a change in the preferred option. Monte Carlo simulations were performed to assess model robustness. RESULTS: Under baseline assumptions, the propofol/fentanyl regimen was the most cost-effective choice (expected cost, 84.06 US dollars), followed by axillary block (88.18 US dollars), K/M (105.32 US dollars), and F/M (159.79 US dollars), respectively. Varying the fixed and variable costs by 50% to 200% of their baseline values did not alter the ranking. When ketamine and propofol were administered without adjunctive midazolam and fentanyl, respectively, propofol remained the optimum choice. With total PSA time as the outcome measure, the incremental cost-effectiveness ratios were 8.1 US dollars and 24.9 US dollars per hour of ED time saved, for propofol/fentanyl versus axillary block and for axillary block versus K/M, respectively. CONCLUSIONS: Among PSA regimens during forearm fracture manipulation in the pediatric ED, propofol/fentanyl is the most cost-effective regimen followed by axillary block, K/M, and F/M.

Analgesics↗
PubMed2006

Visit-level acuity and resource-based relative value unit utilization in a pediatric emergency department.

OBJECTIVE: There is currently limited data on the distribution of evaluation and management (E&M) codes and resource utilization in pediatric emergency departments. We sought to ascertain the following: (1) the distribution of visit-level acuity among patients who sought care in our pediatric emergency department (PED); (2) mean relative value units per physician hour (RVUs/h) as a measure of health care provider productivity; (3) the extent of correlation between the mean number of patients seen per hour and RVUs/h; and (4) the difference in RVU's generated using observation codes versus a higher level E&M code for diagnoses that require an extended level of service. DESIGN/METHODS: The study was conducted at an urban tertiary level, university-affiliated PED in a freestanding children's hospital. After obtaining data from patient encounters during the period from January through December 2004, we calculated total RVUs by using 2004 national Medicare data that pertained to facility coding, adjusted for data from Tennessee. We also reviewed the frequency of 3 diagnoses that usually require extended care to determine disposition (status asthmaticus [International Classification of Disease-9 Diagnosis Code 493.91], volume depletion [276.5], and sickle cell disease with crisis [282.62]). Utilizing a high-level E&M code (99285) and high-level, same day observation code (99236), we compared RVUs generated for each of the earlier said diagnoses. RESULTS: During the study period, 61,444 patient encounters occurred. Of the patients seen, 4678 (7.6%) were admitted. The most common E&M code used was 99283 (53.7%). The mean RVU's/h for pediatric emergency medicine physicians and for pediatricians (and nurse practitioners) were 4.36 and 3.08, respectively. There was high correlation between RVU's/h and the number of patients seen per hour (r = 0.85). The cumulative frequency of the 3 diagnoses that required extended care was 2602. Total RVUs generated when the high-level E&M code 99285 and the high-level observation code 99236 were used was 10,408 and 15,143, respectively. CONCLUSIONS: Our descriptive study provides PED benchmarking data on E&M code distribution and RVU utilization. RVU's/h may serve as a reliable measure of productivity. Although the use of observational codes in the PED requires additional documentation, their use for select diagnoses may appropriately reflect the level of service and have a favorable impact on the total number of RVU's generated.

Child↗
PubMed2006

Successful implementation of a radiology sedation service staffed exclusively by pediatric emergency physicians.

OBJECTIVE: As the number of diagnostic imaging studies performed has increased, the demand for sedation in support of these radiologic tests has also increased. Our objectives were to (1) assess the safety and efficacy of a radiology sedation service that is staffed exclusively by pediatric emergency medicine (PEM) physicians, (2) determine the frequency and the type of commonly performed pediatric imaging studies that require procedural sedation, and (3) assess the average duration of procedural sedation for commonly performed radiologic studies. METHODS: We conducted a retrospective observational study of patient encounters in 2004 involving procedural sedation to facilitate diagnostic imaging. We are a university-affiliated group of PEM physicians that provide a radiology sedation service during weekdays at a freestanding urban children's hospital. RESULTS: The sedation service participated in 1285 patient encounters during the study period. Deep sedation was provided to 1027 patients. Moderate sedation was administered to 258 patients. Procedural sedation times for the most frequently performed imaging studies ranged from 5 to 183 minutes. Agents that were used to provide deep sedation were pentobarbital (with midazolam, fentanyl, or both) in 65% of cases, propofol in 31%, and ketamine (with or without midazolam) in 4%. Moderate sedation was achieved with chloral hydrate in 86% and oral diazepam in 14% of the cases. A total of 99.1% of the imaging studies were completed successfully. Six imaging studies were aborted because of failed sedation or occurrence of adverse event. Five patients who were deemed high risk on their presedation evaluation were referred electively for general anesthesia. CONCLUSIONS: Our data suggest that a dedicated sedation team in support of diagnostic imaging services, staffed exclusively by PEM physicians, can be a successful clinical enterprise. The service consumes significant resources and physician time.

Child↗
PubMed2005

Does lidocaine gel alleviate the pain of bladder catheterization in young children? A randomized, controlled trial.

OBJECTIVE: Bladder catheterization (BC) is a commonly performed, painful procedure in the pediatric emergency department (ED). A survey demonstrated that analgesia is infrequently used for several brief painful procedures, including BC, in pediatric patients. In this study, we evaluated the use of 2% lidocaine gel to alleviate the pain associated with BC in young children (<2 years) in the ED. METHODS: We conducted a randomized, double-blind, placebo-controlled trial comparing pain scores during bladder catheterization with 2% lidocaine gel versus nonanesthetic lubricant. We used a previously validated scale for measuring brief procedure-related pain in preverbal children (Face Legs Arms Cry Consolability Pain Scale [FLACC]). A total of 115 patients were recruited; 56 patients were randomized to the control group, and 59 were randomized to the lidocaine group. Lubricant was applied to both the genital mucosa and the catheter. Pain measurements were recorded at 3 time intervals: before insertion of the catheter, during catheterization, and after catheterization. Interobserver reliability had been previously established in an observational pilot study. RESULTS: The difference in mean FLACC scores between the control (7.55 +/- 2.56) and study groups (7.37 +/- 2.87) during catheterization was not statistically significant. The change in FLACC from time 1 (preprocedure) to time 2 (during procedure) was statistically significant in both groups, suggesting that bladder catheterization is a painful procedure. CONCLUSIONS: Altering the standard practice of use of nonanesthetic lubricant with 2% lidocaine gel as lubricant during bladder catheterization in young children may not be helpful in alleviating the pain associated with the procedure.

Anesthetics, Local↗
PubMed2004

Bedside limited echocardiography by the emergency physician is accurate during evaluation of the critically ill patient.

OBJECTIVE: Echocardiography can be a rapid, noninvasive, objective tool in the assessment of ventricular function and preload during resuscitation of a critically ill or injured child. We sought to determine the accuracy of bedside limited echocardiography by the emergency physician (BLEEP) in estimation of (1) left ventricular function (LVF) and (2) inferior vena cava (IVC) volume, as an indirect measure of preload. METHODS: We conducted a prospective observational study of a convenience sample of patients who were admitted to our intensive care unit. All patients underwent BLEEP followed by an independent formal echocardiogram by an experienced pediatric echocardiography provider (PEP). IVC volume was assessed by measurement of the maximal diameter of the IVC. LVF was determined by calculating shortening fraction (SF) using M-mode measurements on the parasternal short-axis view at the level of the papillary muscle. An independent blinded pediatric cardiologist reviewed all images for accuracy and quality. Estimates of SF obtained on the BLEEP examination were compared with those obtained by the PEP. RESULTS: Thirty-one patients were enrolled. The mean age was 5.1 years (range: 23 days-16 years); 48.4% (15 of 31) were girls; 58.1% (18 of 31) were on mechanical ventilatory support at the time of their study. There was good agreement between the emergency physician (EP) and the PEP for estimation of SF (r = 0.78). The mean difference in the estimate of SF between the providers was 4.4% (95% confidence interval: 1.6%-7.2%). This difference in estimate of SF was statistically significant. Similarly, there was good agreement between the EP and the PEP for estimation of IVC volume (r = 0.8). The mean difference in the estimate of IVC diameter by the PEP and the EP was 0.068 mm (95% confidence interval: -0.16 to 0.025 mm). This difference was not statistically significant. CONCLUSIONS: Our study suggests that PEP sonographers are capable of obtaining images that permit accurate assessment of LVF and IVC volume. BLEEP can be performed with focused training and oversight by a pediatric cardiologist.

Adolescent↗
PubMed2004

Propofol for procedural sedation in the pediatric emergency department.

This retrospective case series reports our experience using propofol for procedural sedation in the Emergency Department over an 18-month period with 52 pediatric patients. Propofol sedation was performed successfully in all children (mean age, 10.2 years; range 0.7-17.4 years). Indications for sedation included orthopedic manipulation, incision and drainage of abscess, sexual assault examination, laceration repair, and non-invasive imaging studies. The mean dose administered with the intermittent bolus and continuous infusion methods of delivery was 4.25 mg/kg (+/- 1.86) and 8.3 mg/kg/h, respectively. The mean recovery time was 27.1 min (+/- 15.84). No patient required assisted ventilation or developed clinically significant hypotension. Respiratory depression requiring airway repositioning or supplemental oxygen was noted in 5.8% (3/52) patients. Propofol is a reasonable alternative to facilitate sedation for a range of procedures performed in a busy Pediatric Emergency Department.

Adolescent↗
PubMed2004

Posterior urethral valves presenting as abdominal distension and undifferentiated shock in a neonate: the role of screening emergency physician-directed bedside ultrasound.

We present a case of shock in a 7-week-old neonate with obstructive uropathy secondary to posterior urethral valves (PUV). The antenatal ultrasound and the 2-week maintenance visit were unremarkable. A screening emergency physician directed bedside ultrasound (SEPUS) served to rapidly establish the diagnosis, initiate appropriate management, and facilitate early relief of urinary obstruction. We discuss the potential role of SEPUS in a critically ill neonate and briefly review the management of PUV.

Catheterization↗
PubMed2003

Early detection of cardiac disease masquerading as acute bronchospasm: The role of bedside limited echocardiography by the emergency physician.

We report two cases in which the patients experienced dyspnea, cough, and acute bronchospasm. Pulmonary pathology was initially suspected. Failure to respond to an initial trial of inhaled bronchodilator prompted the use of bedside limited echocardiography by the emergency physician. The potential role of limited echocardiography by the emergency physician as a triage tool in facilitating early diagnosis and emergent therapy, reducing time to final discharge, and enhancing interaction between the pediatric emergency physician and cardiology consultants is highlighted.

Albuterol↗
PubMed2003

Comparison of propofol/fentanyl versus ketamine/midazolam for brief orthopedic procedural sedation in a pediatric emergency department.

PURPOSE: To compare the effectiveness of 2 medication regimens, propofol/fentanyl (P/F) and ketamine/midazolam (K/M), for brief orthopedic emergency department procedural sedation. This study was powered to compare recovery times (RT) and procedural distress as measured by the Observational Score of Behavioral Distress-revised (OSBD-r; range: 0-23.5 with 23.5 representing maximal distress). METHODS: We conducted a prospective, partially-blinded controlled comparative trial comparing intravenous P/F with K/M in a convenience sample of 113 patients aged 3 to 18 years old undergoing orthopedic procedural sedation. All medications were administered by the intermittent intravenous bolus method. An independent sedation nurse recorded total sedation time and RT. Effectiveness was measured using 6 parameters: 1) patient distress as assessed by independent blinded observers after videotape review using the OSBD-r; 2) orthopedic satisfaction score (Likert scale 1-5); 3) sedation nurse satisfaction score (Likert 1-5); 4) parental perception of procedural pain using a 0 to 100 mm Visual Analog Scale with the upper limit being "most pain"; 5) patient recall of the procedure; and 6) 1 to 3 week follow-up. RESULTS: RT and total sedation time were significantly less in the P/F group than in the K/M group (33.4 minutes vs 23.2 minutes). The mean OSBD-r scores during manipulation were 0.084 and 0.278 for the K/M and P/F groups, respectively. Although this difference was statistically significant (95% confidence interval for the mean difference -0.34 to -0.048), both regimens were successful in keeping the scores low. There was no statistical difference between the groups in the other measures of effectiveness. There was a statistically significant difference between the groups in the occurrence of desaturation and late side effects. CONCLUSIONS: RT with P/F is shorter than with K/M. P/F is comparable to K/M in reducing procedural distress associated with painful orthopedic procedures in the pediatric emergency department. Although propofol has a greater potential of respiratory depression and airway obstruction as compared with ketamine, it offers some unique advantages including a quicker offset and smoother recovery profile.

Adolescent↗
PubMedDate not supplied

Axillary block for analgesia during manipulation of forearm fractures in the pediatric emergency department a prospective randomized comparative trial.

Our objective was to compare procedural distress during manipulation of forearm fractures in children receiving either axillary (brachial plexus) block regional anesthesia (20 children) or deep sedation with ketamine and midazolam (21 children). This was a prospective randomized unmasked controlled comparative trial conducted in an urban children's hospital emergency department. The 2 groups were similar in age (older than 8 years), fracture types, initial pain scores, narcotic analgesia received, and midazolam doses before fracture manipulation. The primary outcome measure was procedural distress during manipulation as measured with the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS). The mean CHEOPS score was 6.4 +/- 2.8 in the group with axillary block and 7.5 +/- 1.6 in those receiving deep sedation; the difference between the CHEOPS scores in the 2 groups was not statistically significant (P = 0.126, 95% CI: 2.5, 0.3). Axillary block was used successfully in 18 (90%) of the 20 children. No patient in either group experienced any adverse events.

Analgesia↗