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Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006 Feb-.

Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet].

Statistical brief #242 overview of pediatric emergency department visits, 2015.

Kimberly W. McDermott , Ph.D., Carol Stocks , Ph.D., R.N., and William J. Freeman , M.P.H.

Published: August 7, 2018 .

• Introduction

Pediatric emergency department (ED) visits constitute roughly 20 percent of all ED visits. 1 In 2015 alone, 17 percent of all children in the United States sought emergency care at least once. 2 Although reasons for pediatric ED visits vary by age, conditions such as wounds, sprains and strains, and viral and respiratory infections are common, as well as symptoms such as fever, cough, nausea, vomiting, and abdominal pain. 3 Of note, some of the most common pediatric diseases and symptoms, including asthma and abdominal pain, have been shown to exhibit seasonal variation. 4 , 5

Although some ill and injured children are treated at children’s hospitals or large pediatric units of medical centers, the vast majority are brought to community hospital EDs. 6 In recent years, national experts have raised concerns about pediatric emergency preparedness in community hospitals and have released guidelines to promote greater equity in pediatric emergency care. 7 , 8 Updated information on patient characteristics and common conditions associated with pediatric ED visits may provide additional insight into the unique needs of the pediatric population and assist community EDs in improving their pediatric care resources.

This Healthcare Cost and Utilization Project (HCUP) Statistical Brief presents data on pediatric ED visits (excluding births), with children defined as patients aged 18 years or younger. 9 The time frame of focus is fiscal year (FY) 2015 (from quarter 4 [Q4] of 2014 through Q3 2015), with comparison data provided for FY 2007 through FY 2014. 10 In this Statistical Brief, FY 2015 will hereinafter be referred to as 2015, FY 2014 will be referred to as 2014, and so forth. The number and rate of pediatric ED visits are compared with adult ED visits in 2015 for three visit types: all ED visits, treat-and-release ED visits, and ED visits resulting in admission to the same hospital. Patient characteristics are presented for pediatric ED visits across these same categories. Trends in pediatric ED visits from 2007 through 2015 are provided by expected primary payer. The most common reasons for pediatric ED visits by body system in 2015 are presented, along with the most common respiratory conditions by age group. Finally, seasonal variation in pediatric ED visits involving respiratory conditions and injuries for 2011 through 2015 are provided. Differences greater than 10 percent between estimates are noted in the text.

• In 2015, there were 30 million ED visits for children aged 18 years or younger, with a rate of 382.9 per 1,000 population. The vast majority of these visits (96.7 percent) were treat and release.
• Infants and children aged <5 years, representing 25.5 percent of all children in the U.S. population, accounted for more than 40 percent of pediatric ED visits in 2015.
• Medicaid was the expected primary payer for more than 60 percent of pediatric ED visits in 2015.
• The number of pediatric ED visits covered by Medicaid increased by more than 50 percent from 2007 to 2015.
• During 2011 through 2015, pediatric ED visits for respiratory conditions peaked from October through March, whereas injury-related ED visits were more frequent from April through September.
• Respiratory disorders, and injury and poisoning were the most common reasons for pediatric ED visits in 2015.
• In 2015, upper respiratory diseases and infections were the most common respiratory-related ED diagnoses across all pediatric age groups, with the highest rate among infants aged <1 year.
• The younger the pediatric age group, the higher the rate of ED visits for influenza in 2015.

Emergency department visits among children compared with adults, 2015

Table 1 compares pediatric ED visits with adult ED visits in 2015. Visit totals and population rates are presented for all ED visits, treat-and-release ED visits, and ED visits resulting in hospital admission, among patients aged 18 years or younger, patients aged 19–64 years, and patients aged 65 years and older. Corresponding U.S. population totals are presented for comparison.

Pediatric ED visits compared with adult ED visits, FY 2015.

• Children had a lower rate of ED visits than adults in 2015. In 2015, there were approximately 30 million pediatric ED visits, with a rate of 382.9 per 1,000 population. This rate was lower than the rate of ED visits among adult patients aged 19–64 years (502.6 per 1,000) and patients aged 65 years and older (576.5 per 1,000).
• Fewer than 5 percent of pediatric ED visits resulted in admission to the same hospital. In 2015, 96.7 percent of pediatric ED visits were treat and release, compared with 89.0 percent of visits among patients aged 19–64 years and 65.9 percent of visits among patients aged 65 years and older.

Patient characteristics related to pediatric ED visits, 2015

Table 2 presents patient characteristics for all pediatric ED visits, treat-and-release pediatric ED visits, and pediatric ED visits resulting in hospital admission in 2015. Corresponding U.S. population totals are presented as a means of comparison.

Patient characteristics for ED visits in the pediatric population, FY 2015.

• Children younger than 5 years of age accounted for more than 40 percent of pediatric ED visits in 2015. The two youngest pediatric age groups—infants younger than 1 year old and children aged 1–4 years—constituted a disproportionately high share of pediatric ED visits. Whereas these age groups accounted for 5.1 and 20.4 percent of the U.S. population, respectively, their treat-and-release ED visits comprised 11.0 and 29.5 percent of all pediatric treat-and-release visits. Infant ED visits accounted for an event greater share (21.3 percent) of admitted pediatric ED visits. Children aged 5–9 years and 10–14 years accounted for a disproportionately low share of pediatric ED visits. This was particularly the case for ED visits resulting in hospital admission. These two age groups each constituted approximately 26 percent of the U.S. population but accounted for only 15.8 and 16.1 percent of admitted pediatric ED visits, respectively. Children aged 15–18 years accounted for 22.1 percent of the U.S. population and a similar share of pediatric treat-and-release and admitted ED visits (19.7 and 23.7 percent, respectively).
• Overall, the proportion of pediatric ED visits was inversely related to community-level income, with children in the lowest income quartile constituting more than a third of pediatric ED visits. In 2015, children in the lowest income quartile constituted a disproportionately high share of pediatric ED visits. This group accounted for 26.6 percent of the U.S. population aged 18 years and younger and 36.4 percent of pediatric ED visits. Conversely, the highest income quartile constituted a disproportionately low share of pediatric ED visits, accounting for 24.9 percent of the U.S. population and only 15.3 percent of pediatric ED visits.
• More than 60 percent of pediatric ED visits in 2015 were covered by Medicaid. Medicaid was the most common primary expected payer among pediatric treat-and-release and admitted ED visits, accounting for 61.6 percent and 59.0 percent of visits, respectively. This was followed by private insurance, which was the expected payer for 28.0 percent of treat-and-release visits and 34.8 percent of ED visits resulting in hospital admission. Pediatric ED visits for patients with no insurance were less common, constituting 6.4 percent and 2.7 percent of treat-and-release and admitted pediatric ED visits, respectively.

Figure 1 presents the number of pediatric ED visits (treat and release or admitted) by expected primary payer from 2007 through 2015.

Trends in the number of pediatric ED visits by expected primary payer, FY 2007–FY 2015. Abbreviation: ED, emergency department; FY, fiscal year Notes: Pediatric ED visits exclude births. The “other” payer category does not include (more...)

• The number of pediatric ED visits covered by Medicaid generally increased from 2007 to 2015, whereas the number of visits covered by other types of insurance generally decreased. Apart from a decline from 2013 to 2014, the number of pediatric ED visits with Medicaid as the primary expected payer increased steadily from 12.3 million in 2007 to 18.5 million in 2015—a 51.0 percent cumulative increase. During the same period, the number of pediatric ED visits with private insurance as the expected payer decreased from 11.8 million to 8.5 million (a 28.2 percent decrease) and the number of visits among uninsured pediatric patients decreased from 3.3 million to 1.9 million (a 42.7 percent decrease).

Reasons for pediatric ED visits, 2015

Figure 2 shows the most common reasons for all pediatric ED visits by body system, based on all-listed diagnoses in 2015.

Ten most common all-listed reasons for pediatric ED visits by body system, FY 2015. Abbreviation: ED, emergency department; FY, fiscal year Notes: Pediatric ED visits exclude births. Totals are rounded to the nearest hundred. Body systems are based on (more...)

• Respiratory disorders, and injury and poisoning (combined) were the most common reasons for pediatric ED visits in 2015. In 2015, 9.6 million pediatric ED visits involved respiratory disorders and 8.2 million pediatric ED visits involved injury or poisoning. Other common reasons included nervous system disorders (4.8 million visits), digestive disorders (3.4 million), and infectious or parasitic diseases (2.6 million).

Figure 3 focuses on the most common reasons for pediatric ED visits—respiratory disorders—and presents population rates for six categories of first-listed ED respiratory diagnoses, by pediatric age group, in 2015.

Six categories of first-listed respiratory conditions among pediatric ED visits by age group, FY 2015. Abbreviation: ED, emergency department; FY, fiscal year Notes: Pediatric ED visits exclude births. To adjust for use of fiscal year data, population (more...)

• Upper respiratory diseases and infections were the most common respiratory-related ED diagnoses across all pediatric age groups in 2015, with the highest rates among younger age groups. Among the youngest two pediatric age groups, the population rate of ED visits for upper respiratory diseases and infections, lower respiratory diseases, and pneumonia was triple (for infants) and double (for children aged 1–4 years) the corresponding rates for older children. For example, infants aged younger than 1 year and children aged 1–4 years had higher rates of ED visits with a first-listed diagnosis of upper respiratory disease or infection—164.2 and 91.7 per 1,000 population, respectively—compared with older pediatric age groups (which ranged from 23.7 to 45.4 per 1,000 population).
• In 2015, the population rate of ED visits for acute bronchitis among infants was nearly 5 times higher than the rate among children aged 1–4 years and more than 22 times higher than the rates among older pediatric age groups. Among infants aged younger than 1 year, the rate of ED visits for acute bronchitis was 59.5 per 1,000 population. This was nearly 5 times higher than the rate for the next oldest pediatric age group (12.3 per 1,000 children aged 1–4 years) and more than 22 times higher than rates among the oldest three pediatric age groups (which ranged from 1.4 to 2.7 per 1,000 population).
• In 2015, the rate of ED visits with a first-listed diagnosis of asthma was highest among children aged 1–4 years and 5–9 years. First-listed ED diagnoses of asthma were most frequent among children aged 1–4 years (14.6 visits per 1,000 population) and children aged 5–9 years (12.3 visits per 1,000 population). At a rate of 5.2 per 1,000 population, ED visits for asthma were relatively uncommon among infants compared with ED visits for other respiratory conditions. In contrast, among older pediatric age groups, asthma was the second or third most common category of first-listed ED conditions.
• The younger the age group, the higher the rate of ED visits for influenza in 2015. Infants younger than 1 year had the highest rate of ED visits for influenza among pediatric age groups (11.4 per 1,000 population). Rates of ED visits with a first-listed diagnosis of influenza were inversely related to age, with the lowest rate of 2.5 per 1,000 population observed among children aged 15–18 years.

Figure 4 presents quarterly trends for two common reasons for pediatric ED visits—respiratory conditions and injuries—from 2011 through 2015. Although the condition category reported in Figure 2 includes both injuries and poisonings, this figure is limited to injury diagnoses to highlight the seasonal variation associated with these conditions. Totals are based on all-listed diagnoses.

Comparison of seasonal variation for two common reasons for pediatric ED visits, FY 2011–FY 2015. Abbreviations: ED, emergency department; FY, fiscal year Note: Pediatric ED visits exclude births. Totals are based on all-listed diagnoses. Body (more...)

• From 2011 through 2015, the number of pediatric ED visits involving respiratory conditions consistently peaked during the months of October through March. During 2011 through 2015, the number of pediatric ED visits associated with respiratory conditions demonstrated strong seasonal variation, with higher volumes from October through March compared with April through September. In FY 2015, for example, there were 2.8 and 3.0 million respiratory-related pediatric ED visits during the quarterly periods of October through December (Q4 2014) and January through March (Q1 2015), respectively, and only 2.1 and 1.7 million visits during April through June (Q2 2015) and July through September (Q3 2015), respectively. This equates to a 43.4 percent decrease from the highest volume quarter (October through December) to the lowest volume quarter (July through September) of that fiscal year.
• Children visited the ED with injuries most frequently during the months of April through September in 2011–2015. Pediatric ED visits involving injury diagnoses showed a clear seasonality from 2011 through 2015. Injury-related visits were far more prevalent from April through September compared with October through March. This pattern was exemplified in FY 2015, when there were 2.2 million injury-related pediatric ED visits in both periods of April through June (Q2 2015) and July through September (Q3 2015), compared with 1.8 and 1.7 million visits during October through December (Q4 2014) and January through March (Q1 2015), respectively. The volume of pediatric ED visits associated with injuries increased by 29.9 percent between the lowest volume quarter (January through March) and the highest volume quarter (July through September) of FY 2015.
• About Statistical Briefs

Healthcare Cost and Utilization Project (HCUP) Statistical Briefs provide basic descriptive statistics on a variety of topics using HCUP administrative health care data. Topics include hospital inpatient, ambulatory surgery, and emergency department (ED) use and costs, quality of care, access to care, medical conditions, procedures, and patient populations, among other topics. The reports are intended to generate hypotheses that can be further explored in other research; the reports are not designed to answer in-depth research questions using multivariate methods.

• Data Source

The estimates in this Statistical Brief are based upon data from the HCUP Q4 2014–Q3 2015 Nationwide Emergency Department Sample (NEDS). Historical data were drawn from the Q4 2006– Q3 2014 NEDS. Supplemental sources included population denominator data for use with HCUP databases, derived from information available from the U.S. Census Bureau 11 and Claritas, a vendor that compiles and adds value to data from the U.S. Census Bureau. 12

For this Statistical Brief, fiscal year (FY) was used. FY includes October through December of one year and January through September of the following year, thereby including all four seasons, as does calendar year.

Beginning FY 2016, on October 1, 2015, the United States transitioned from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) clinical coding system to the International Classification of Diseases, Tenth Revision, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS) clinical coding system. Although the impact of the change in coding systems on pediatric ED diagnoses has not been studied directly, the change has been observed to result in substantial shifts in the overall number of ED visits for some of the most frequent diagnoses. 13 Although the coding change did not affect calendar years prior to 2015, FYs for all data reported in this Statistical Brief (2007–2015) were used to allow for comparability across years.

• Definitions

Diagnoses, ICD-9-CM, Clinical Classifications Software (CCS), and body systems

The first-listed diagnosis is the condition, symptom, or problem identified in the medical record to be chiefly responsible for the emergency department (ED) services provided. For ED visits that result in an inpatient admission to the same hospital, the first-listed diagnosis is the principal diagnosis, the condition established after study to be chiefly responsible for the patient’s admission to the hospital. All-listed diagnoses include the first-listed diagnosis plus concomitant conditions that coexist at the time of the visit.

ICD-9-CM is the International Classification of Diseases, Ninth Revision, Clinical Modification, which assigns numeric codes to diagnoses. There are approximately 14,000 ICD-9-CM diagnosis codes.

CCS categorizes ICD-9-CM diagnosis codes into a manageable number of clinically meaningful categories. 14 This clinical grouper makes it easier to quickly understand patterns of diagnoses. CCS categories identified as Other typically are not reported; these categories include miscellaneous, otherwise unclassifiable diagnoses that may be difficult to interpret as a group.

The single-level CCS aggregates illnesses and conditions into 285 mutually exclusive diagnosis categories. The multilevel CCS expands the single-level CCS into a hierarchical system that groups single-level CCS categories into broader body systems or condition categories (e.g., Diseases of the Respiratory System and Injury and Poisoning).

Case definition

For this report, pediatric ED visits were defined as ED visits involving patients aged 18 years or younger. ED visits for births were excluded. Births were identified as having an ICD-9-CM diagnosis code of V3000 through V3901, with the last two digits being 00 or 01 in any diagnosis field.

• The numerator used HCUP data from October 2014 to September 2015
• The denominator used the sum of one-quarter of the 2014 U.S. population and three-quarters of the 2015 U.S. population

Types of hospitals included in the HCUP Nationwide Emergency Department Sample

The Nationwide Emergency Department Sample (NEDS) is based on data from community hospitals, which are defined as short-term, non-Federal, general, and other hospitals, excluding hospital units of other institutions (e.g., prisons). The NEDS includes specialty, pediatric, public, and academic medical hospitals. Excluded are long-term care facilities such as rehabilitation, psychiatric, and alcoholism and chemical dependency hospitals. Hospitals included in the NEDS have hospital-owned EDs and no more than 90 percent of their ED visits resulting in admission.

ED visits include information on all visits to hospital-owned EDs regardless of whether the patient was treated and released from that ED or admitted to the same hospital from the ED.

Treat-and-release ED visits were defined as those ED visits in which patients were treated and then released from the ED; that is, patients were not admitted to the specific hospital associated with the ED.

ED visits resulting in admission to the same hospital included those patients initially seen in the ED who were then admitted to the specific hospital associated with that ED.

Unit of analysis

The unit of analysis is the ED visit, not a person or patient. This means that a person who is seen in the ED multiple times in 1 year will be counted each time as a separate visit in the ED.

Location of patients’ residence

Place of residence is based on the urban-rural classification scheme for U.S. counties developed by the National Center for Health Statistics (NCHS) and based on the Office of Management and Budget (OMB) definition of a metropolitan service area as including a city and a population of at least 50,000 residents.

• Large Central Metropolitan: Counties in a metropolitan area with 1 million or more residents that satisfy at least one of the following criteria: (1) containing the entire population of the largest principal city of the metropolitan statistical area (MSA), (2) having their entire population contained within the largest principal city of the MSA, or (3) containing at least 250,000 residents of any principal city in the MSA
• Large Fringe Metropolitan: Counties in a metropolitan area with 1 million or more residents that do not qualify as large central metropolitan counties
• Medium and Small Metropolitan: Counties in a metropolitan area of 50,000–999,999 residents
• Micropolitan and Noncore: Counties in a nonmetropolitan area (i.e., counties with no town greater than 49,999 residents).

Community-level income

Community-level income is based on the median household income of the patient’s ZIP Code of residence. Quartiles are defined so that the total U.S. population is evenly distributed. Cut-offs for the quartiles are determined annually using ZIP Code demographic data obtained from Claritas, a vendor that adds value to data from the U.S. Census Bureau. 15 The value ranges for the income quartiles vary by year. The income quartile is missing for patients who are homeless or foreign.

• Medicaid: includes patients covered by fee-for-service and managed care Medicaid
• Private Insurance: includes Blue Cross, commercial carriers, and private health maintenance organizations (HMOs) and preferred provider organizations (PPOs)
• Uninsured: includes an insurance status of self-pay and no charge
• Other: includes Medicare, Workers’ Compensation, TRICARE/CHAMPUS, CHAMPVA, Title V, and other government programs. Note that for this Statistical Brief, Medicare is included in the Other category because of the small number of children covered by the Medicare Program.

Hospital stays billed to the State Children’s Health Insurance Program (SCHIP) may be classified as Medicaid, Private Insurance, or Other, depending on the structure of the State program. Because most State data do not identify patients in SCHIP specifically, it is not possible to present this information separately.

For this Statistical Brief, when more than one payer is listed for a hospital discharge, the first-listed payer is used.

• Northeast: Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut, New York, New Jersey, and Pennsylvania
• Midwest: Ohio, Indiana, Illinois, Michigan, Wisconsin, Minnesota, Iowa, Missouri, North Dakota, South Dakota, Nebraska, and Kansas
• South: Delaware, Maryland, District of Columbia, Virginia, West Virginia, North Carolina, South Carolina, Georgia, Florida, Kentucky, Tennessee, Alabama, Mississippi, Arkansas, Louisiana, Oklahoma, and Texas
• West: Montana, Idaho, Wyoming, Colorado, New Mexico, Arizona, Utah, Nevada, Washington, Oregon, California, Alaska, and Hawaii

Discharge status

Discharge status reflects the disposition of the patient at discharge from the ED and includes the following seven categories: routine (to home); transfer to a different short-term hospital; other transfers (including skilled nursing facility, intermediate care, and another type of facility such as a nursing home); home health care; against medical advice (AMA); died in the hospital; or destination unknown.

The Healthcare Cost and Utilization Project (HCUP, pronounced “H-Cup”) is a family of health care databases and related software tools and products developed through a Federal-State-Industry partnership and sponsored by the Agency for Healthcare Research and Quality (AHRQ). HCUP databases bring together the data collection efforts of State data organizations, hospital associations, and private data organizations (HCUP Partners) and the Federal government to create a national information resource of encounter-level health care data. HCUP includes the largest collection of longitudinal hospital care data in the United States, with all-payer, encounter-level information beginning in 1988. These databases enable research on a broad range of health policy issues, including cost and quality of health services, medical practice patterns, access to health care programs, and outcomes of treatments at the national, State, and local market levels.

• Alaska Department of Health and Social Services
• Alaska State Hospital and Nursing Home Association
• Arizona Department of Health Services
• Arkansas Department of Health
• California Office of Statewide Health Planning and Development
• Colorado Hospital Association
• Connecticut Hospital Association
• District of Columbia Hospital Association
• Florida Agency for Health Care Administration
• Georgia Hospital Association
• Hawaii Health Information Corporation
• Illinois Department of Public Health
• Indiana Hospital Association
• Iowa Hospital Association
• Kansas Hospital Association
• Kentucky Cabinet for Health and Family Services
• Louisiana Department of Health
• Maine Health Data Organization
• Maryland Health Services Cost Review Commission
• Massachusetts Center for Health Information and Analysis
• Michigan Health & Hospital Association
• Minnesota Hospital Association
• Mississippi State Department of Health
• Missouri Hospital Industry Data Institute
• Montana Hospital Association
• Nebraska Hospital Association
• Nevada Department of Health and Human Services
• New Hampshire Department of Health & Human Services
• New Jersey Department of Health
• New Mexico Department of Health
• New York State Department of Health
• North Carolina Department of Health and Human Services
• North Dakota (data provided by the Minnesota Hospital Association)
• Ohio Hospital Association
• Oklahoma State Department of Health
• Oregon Association of Hospitals and Health Systems
• Oregon Office of Health Analytics
• Pennsylvania Health Care Cost Containment Council
• Rhode Island Department of Health
• South Carolina Revenue and Fiscal Affairs Office
• South Dakota Association of Healthcare Organizations
• Tennessee Hospital Association
• Texas Department of State Health Services
• Utah Department of Health
• Vermont Association of Hospitals and Health Systems
• Virginia Health Information
• Washington State Department of Health
• West Virginia Department of Health and Human Resources, West Virginia Health Care Authority
• Wisconsin Department of Health Services
• Wyoming Hospital Association
• About the NEDS

The HCUP Nationwide Emergency Department Database (NEDS) is a unique and powerful database that yields national estimates of emergency department (ED) visits. The NEDS was constructed using records from both the HCUP State Emergency Department Databases (SEDD) and the State Inpatient Databases (SID). The SEDD capture information on ED visits that do not result in an admission (i.e., patients who were treated in the ED and then released from the ED, or patients who were transferred to another hospital); the SID contain information on patients initially seen in the ED and then admitted to the same hospital. The NEDS was created to enable analyses of ED utilization patterns and support public health professionals, administrators, policymakers, and clinicians in their decisionmaking regarding this critical source of care. The NEDS is produced annually beginning in 2006. Over time, the sampling frame for the NEDS has changed; thus, the number of States contributing to the NEDS varies from year to year. The NEDS is intended for national estimates only; no State-level estimates can be produced.

• For More Information

For other information on pediatric emergency department (ED) visits and hospital stays, refer to the HCUP Statistical Briefs located at www.hcup-us.ahrq.gov/reports/statbriefs/sb_pediatric.jsp .

• HCUP Fast Stats at www.hcup-us.ahrq.gov/faststats/landing.jsp for easy access to the latest HCUP-based statistics for health care information topics
• HCUPnet, HCUP’s interactive query system, at www.hcupnet.ahrq.gov/

For more information about HCUP, visit www.hcup-us.ahrq.gov/ .

For a detailed description of HCUP and more information on the design of the Nationwide Emergency Department Sample (NEDS), please refer to the following database documentation:

Agency for Healthcare Research and Quality. Overview of the Nationwide Emergency Department Sample (NEDS). Healthcare Cost and Utilization Project (HCUP). Rockville, MD: Agency for Healthcare Research and Quality. Updated December 2017. www.hcup-us.ahrq.gov/nedsoverview.jsp . Accessed January 18, 2018.

• Acknowledgments

The authors would like to acknowledge the contributions of Minya Sheng of IBM Watson Health.

Moore BJ, Stocks C, Owens PL. Trends in Emergency Department Visits, 2006–2014. HCUP Statistical Brief #227. September 2017. Agency for Healthcare Research and Quality, Rockville, MD. www ​.hcup-us.ahrq.gov ​/reports/statbriefs/sb227-Emergency-Department-Visit-Trends ​.pdf

National Center for Health Statistics. Health, United States, 2016: With Chartbook on Long-Term Trends in Health. Table 73. Emergency Department Visits Within the Past 12 Months Among Children Under Age 18, by Selected Characteristics: United States, Selected Years 1997–2015. Centers for Disease Control and Prevention, National Center for Health Statistics. www ​.cdc.gov/nchs/data/hus/hus16.pdf#073 . Accessed April 4, 2018.

Wier LM, Yu H, Owens PL, Washington R. Overview of Children in the Emergency Department, 2010. HCUP Statistical Brief #157. June 2013. Agency for Healthcare Research and Quality, Rockville, MD. www ​.hcup-us.ahrq.gov ​/reports/statbriefs/sb157.pdf

Cohen HA, Blau H, Hoshen M, Batat E, Balicer RD. Seasonality of asthma: a retrospective population study. Pediatrics. 2014;133(4):e923–32 [ PubMed : 24616356 ].

Saps M, Blank C, Khan S, Seshadri R, Marshall BM, Bass LM, et al Seasonal variation in the presentation of abdominal pain. Journal of Pediatric Gastroentrology and Nutrition. 2008;46(3):279–84 [ PubMed : 18376244 ].

American Academy of Pediatrics, Committee on Pediatric Emergency Medicine; American College of Emergency Physicians, Pediatric Committee; Emergency Nurses Association, Pediatric Committee. Joint policy statement: guidelines for care of children in the emergency department. Journal of Emergency Nursing. 2013;39(2):116–31 [ PubMed : 23498882 ].

Institute of Medicine, Committee of the Future of Emergency Care in the US Health System. Emergency Care for Children: Growing Pains. Washington, DC: National Academy Press; 2006.

This definition aligns with the definition of child used by the Children’s Health Insurance Program (CHIP) to determine eligibility.

FYs were used in this Statistical Brief because beginning FY 2016, on October 1, 2015, the United States transitioned from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) clinical coding system to the International Classification of Diseases, Tenth Revision, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS) clinical coding system. Although the impact of the change in coding systems on pediatric ED diagnoses has not been studied directly, the change has been observed to result in substantial shifts in the overall number of ED visits for some of the most frequent diagnoses (ref. Moore BJ, McDermott KW, Elixhauser A. ICD-10-CM Diagnosis Coding in HCUP Data: Comparisons With ICD-9-CM and Precautions for Trend Analyses. November 28, 2017. Rockville, MD: U.S. Agency for Healthcare Research and Quality. www ​.hcup-us.ahrq.gov ​/datainnovations/ICD-10 ​_DXCCS_Trends112817.pdf ). Although the coding change did not affect calendar years prior to 2015, FYs for all data reported in this Statistical Brief (2007–2015) were used to allow for comparability across years.

Barrett M, Coffey R, Levit K. Population Denominator Data for Use with the HCUP Databases (Updated with 2016 Population Data). HCUP Methods Series Report #2017-04. October 17, 2017. U.S. Agency for Healthcare Research and Quality. www ​.hcup-us.ahrq.gov ​/reports/methods/2017-04.pdf . Accessed January 18, 2018.

Claritas. Claritas Demographic Profile by ZIP Code. https://claritas360 ​.claritas ​.com/mybestsegments/ . Accessed June 6, 2018.

Moore BJ, McDermott KW, Elixhauser A. ICD-10-CM Diagnosis Coding in HCUP Data: Comparisons With ICD-9-CM and Precautions for Trend Analyses. November 28, 2017. U.S. Agency for Healthcare Research and Quality. https://www ​.hcup-us.ahrq ​.gov/datainnovations ​/ICD-10_DXCCS_Trends112817.pdf . Accessed, July 5, 2018.

Agency for Healthcare Research and Quality. HCUP Clinical Classifications Software (CCS) for ICD-9-CM. Healthcare Cost and Utilization Project (HCUP). Agency for Healthcare Research and Quality. Updated March 2017. www ​.hcup-us.ahrq.gov ​/toolssoftware/ccs/ccs.jsp . Accessed January 18, 2018.

McDermott KW (IBM Watson Health), Stocks C (AHRQ), Freeman WJ (AHRQ). Overview of Pediatric Emergency Department Visits, 2015. HCUP Statistical Brief #242. August 2018. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov/reports/statbriefs/sb242-Pediatric-ED-Visits-2015.pdf .

• Cite this Page McDermott KW, Stocks C, Freeman WJ. Overview of Pediatric Emergency Department Visits, 2015. 2018 Aug 7. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006 Feb-. Statistical Brief #242.
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• Healthcare Cost and Utilization Project (HCUP)
• Nationwide Inpatient Sample (NIS)
• Kids' Inpatient Database (KID)
• Nationwide Emergency Department Sample (NEDS)
• State Inpatient Databases (SID)
• State Ambulatory Surgery Databases (SASD)
• State Emergency Department Databases (SEDD)
• HCUP Overview
• HCUP Fact Sheet
• HCUP Partners
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10 things for parents to know before heading to the er.

​​​​By: Sylvia Owusu-Ansah MD, MPH, FAAP

Sooner or later, you will find yourself taking your child to the emergency room (ER)—it's bound to happen. Nearly 30 million children visit the ER each year in the United States!

Here are 10 tips to help you know what to expect and be better prepared when your time comes.

1. Plan Ahead and Consider a Pediatric Emergency Room

In a serious emergency, you should always go to the closest ER—period. Do you know where your nearest ER is located? Do you know which hospital your pediatrician is affiliated with?

If you take your child to an urgent care center or ER that does not have pediatricians or pediatric specialists on staff, your child may need to be transferred to a hospital that does depending on his or her condition.

Children's hospitals, for example, have an atmosphere more geared to children—colorful rooms and murals, waiting room toys and TVs tuned to kids' shows, and child-sized furniture. Some children's hospitals and pediatric emergency departments also have child life specialists on staff. They are highly trained to help families and can be an excellent resource to make your child's stay more comfortable in the ER and provide a bridge between the hospital and home. Child life specialists also help to ease your child's anxiety before, during, and after procedures.

2. Call Your Pediatrician First

If you can reach your pediatrician's office, do so. They can give advice on the phone and, if you do need to head to the ER, your pediatrician can call ahead and tell the ER staff to expect you. In a serious emergency, parents should not hesitate to call 911.

3. Treat Your Child at Home

It is ok to give your child over-the-counter fever or pain medicines before heading to the ER—The medicine will make a huge difference and often makes the examination process a lot easier. Remember to take note of the time and dosage you gave your child, as it will be one of the first questions you are asked in the ER.

4. Stay Calm and Tell Your Child What to Expect

When you panic, your child's anxiety level goes up. For many kids, the anxiety about what's going to happen is worse than the actual pain. Children of all ages look to their parents for reassurance, so it is important to keep communicating. Be honest, but also be sensitive to the situation and his or her age. Let your child know that everyone is there to help.

5. Leave Siblings at Home

If possible, make arrangements so you don't have to bring young siblings to the ER with you. This way, you can focus on the needs of your sick child, and your other children do not have to endure the waiting time. Note that you will need to stay with your child throughout his or her ER stay and are strongly encouraged to stay in the hospital with your child if he or she is admitted.

6. Bring Your Child's Medical History and a List of Medications

It's always a good idea to have the following information readily available . You may be asked this information by multiple providers and staff in the ER: 

Health insurance

Your child's primary pediatrician and any other doctors' names and contact information

Known allergies

Past medical and surgical history

List of current medications (including prescriptions, over-the-counter painkillers, homeopathic medicines, vitamins, and supplements)

A chronological sequence of events leading to your child's ER visit

It is also important to know the time your child last ate. Many ERs do not allow patients to have anything to eat or drink until the doctor says it is OK. The main reason is to protect your child if he needs to have a procedure done and/or receive any medications that require an empty stomach. During this time, it's a good idea to refrain from eating in front of your child.

7. A Comfort Item Can Go a Long Way

If your child requires a special item to rest or feel at ease, don't hesitate to bring it. A lovey, toy, blanket, book, etc. can help take your child's mind off the pain and less anxious in an unfamiliar place.

8. ERs are Not First Come, First Serve

Understand that there may be good reasons to wait in the ER. The sickest patients are seen first. If your pediatrician calls the hospital before your arrival, however, it can sometimes help speed up the process. In addition, depending on how sick your child is, he or she may need blood work and/or imaging . Realize that it can take a long time for lab work and/or imaging results to come back. As they say, patience is a virtue!

9. You Know Your Child Best—Speak Up!

As a parent, you are the best advocate for your child and the best interpreter of his or her needs. If you think your child is in pain, say so. If you don't think he or she is ready to go home, tell a member of the ER team.

Don't be afraid to ask repeated questions and be patient. You and your child will meet lots of different people—the ER is a multidisciplinary team. Repeating your story and providing background to each doctor can seem redundant, but it is essential to getting the best care for your child.

10. Follow Up with Your Pediatrician

After the ER visit, call your pediatrician's office and inform them about the diagnosis. Many ERs will also send a report to your pediatrician's office if you ask them to. Check to see whether your pediatrician has received the report or if he or she has any further recommendations. Many times, your pediatrician will ask to see your child for a follow-up exam.

Additional Information:

When Your Child Needs Emergency Medical Services

Emergency Medical Treatment

Children and Broken Bones

Guidelines for Care of Children in the Emergency Department (AAP Policy Statement)

Relief of Pain and Anxiety in Pediatric Patients in Emergency Medical Systems (EMS) (AAP Clinical Report)

Pediatric Care Recommendations for Freestanding Urgent Care Facilities (AAP Policy Statement)

About Dr. Owusu-Ansah:

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1:  Approach to the Pediatric Emergency Department Patient

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It is important for the emergency physician to be capable of managing pediatric emergencies when they present. Children are a unique and significant subset of patients presenting to the emergency department. In 2010 the Center for Disease Control (CDC) database reported a total of 129.8 million emergency department visits in the United States: 25.5 million visits were patients younger than 15 years, and an additional 20.7 million visits were patients between 15 and 24 years. The emergency physician should be prepared to care for pediatric emergencies, whether they present to a children’s hospital, tertiary referral center, or community hospital. Additionally, the presenting child at an adult hospital may develop an airway problem, acute allergic reaction, or other life-threatening event.

What is the best way for the physician to assess a pediatric emergency department patient? The challenges are to simultaneously obtain a history, perform a physical examination, and determine if the child requires an intervention immediately or whether treatment can wait.

Evaluation of a child in the emergency department begins with an assessment of mental status. Children naturally investigate their environment. A child that does not track the examiner could have a visual deficit or other neurologic issue. A child that is sleeping normally at the time of the encounter would be expected to be less attentive when awoken, whereas a somnolent or lethargic child is a potential emergency.

Respiratory function should be assessed in the initial moments when the physician enters the room. Evaluation of respiratory effort, rate, and oxygen saturation should be made. Stridor is an indication of a potentially obstructed airway and should elicit concern. Acquired upper airway obstruction can be systematically evaluated and should be treated accordingly.

Temperature should be measured at the onset of the visit. Infants younger than 2 months are particularly vulnerable because their immunity has not developed fully and transplacental immunity provided by the mother is declining. Preterm infants are at even greater risk. Fever may prompt a sepsis workup.

The emergency physician needs to obtain a history as well, and should be particularly interested in what prompted the current visit, including what caregivers know and suspect. Past medical history will primarily focus on the conditions, workups, or admissions the child has experienced, which may lend important insight to the visit. Immunization status will also be important to determine if the child is at risk for preventable illnesses.

Review of family history is important. Open-ended questions are most helpful and often raise differential diagnostic possibilities. Close family members may have had atypical presentations of common disease processes. For example, the wise physician will pay attention when family states the child’s father had the same symptoms and was later discovered to have appendicitis.

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Sample includes 25 EDs from the Michigan Emergency Department Improvement Collaborative (MEDIC). Weekly visit counts are depicted for 2021 and 2022 and indicate low- and moderate-volume ( z score, <1), high-volume ( z score, 1-2), and highest-volume ( z score, >2) EDs. Michigan experienced a significant surge in pediatric respiratory cases related to influenza, COVID-19, and respiratory syncytial virus infections beginning in September 2022 (shaded). Smoothed curves are generated using locally weighted scatterplot smoothing (span, 0.32) with 95% CI regions using previously described methods.

eTable 1. Most Common Chief Complaints Defining Sample Cohort

eTable 2. Most Common Diagnosis Codes Defining Sample Cohort

eTable 3. Sample Emergency Department Sites from the Michigan Emergency Department Improvement Collaborative

eTable 4. Sample Sociodemographic Characteristics of Pediatric Viral and Respiratory Visits

eTable 5. Sample Pediatric Viral Respiratory Visit Characteristics

eTable 6. High Acuity and Transfer Visits for Lengths of Stay >12 Hours During the Surge Period

eTable 7. High-Acuity and Hospitalizations for ED Revisits During the Surge Period

eFigure 1 . Distribution of Wait Times Across Site Types for Pediatric Viral and Respiratory Visits, January 1, 2021, to December 31, 2022

eFigure 2 . Distribution of Lengths of Stay Across Site Types for Pediatric Viral and Respiratory Visits, January 1, 2021, to December 31, 2022

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Janke AT , Mangus CW , Fung CM, et al. Emergency Department Care for Children During the 2022 Viral Respiratory Illness Surge. JAMA Netw Open. 2023;6(12):e2346769. doi:10.1001/jamanetworkopen.2023.46769

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Emergency Department Care for Children During the 2022 Viral Respiratory Illness Surge

• 1 National Clinician Scholars Program, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
• 2 Department of Emergency Medicine, University of Michigan, Ann Arbor
• 3 Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
• 4 Department of Pediatrics, University of Michigan, Ann Arbor
• 5 Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
• 6 Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
• 7 Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
• 8 Department of Learning Health Sciences, University of Michigan, Ann Arbor

Question   Was a surge in viral and respiratory cases differentially associated with emergency department (ED) care at children’s hospitals in a statewide quality collaborative?

Findings   In this cohort study of more than 2.7 million ED visits, prolonged wait times and lengths of stay were common at children’s hospitals. Greater visit volumes were associated with increased likelihood of ED revisits across hospitals.

Meaning   Periods of illness surge have differential associations with ED care for children by setting, highlighting the importance of coordinating pediatric readiness and surge preparedness across diverse EDs.

Importance   Pediatric readiness is essential for all emergency departments (EDs). Children’s experience of care may differ according to operational challenges in children’s hospitals, community hospitals, and rural EDs caused by recurring and sometimes unpredictable viral illness surges.

Objective   To describe wait times, lengths of stay (LOS), and ED revisits across diverse EDs participating in a statewide quality collaborative during a surge in visits in 2022.

Design, Setting, and Participants   This retrospective cohort study included 25 EDs from the Michigan Emergency Department Improvement Collaborative data registry from January 1, 2021, through December 31, 2022. Pediatric (patient age <18 years) encounters for viral and respiratory conditions were analyzed, comparing wait times, LOS, and ED revisit rates for children’s hospital, urban pediatric high-volume (≥10% of overall visits), urban pediatric low-volume (<10% of overall visits), and rural EDs.

Exposures   Surge in ED visit volumes for children with viral and respiratory illnesses from September 1 through December 31, 2022.

Main Outcomes and Measures   Prolonged ED visit wait times (arrival to clinician assigned, >4 hours), prolonged LOS (arrival to departure, >12 hours), and ED revisit rate (ED discharge and return within 72 hours).

Results   A total of 2 761 361 ED visits across 25 EDs in 2021 and 2022 were included. From September 1 to December 31, 2022, there were 301 688 pediatric visits for viral and respiratory illness, an increase of 71.8% over the 4 preceding months and 15.7% over the same period in 2021. At children’s hospitals during the surge, 8.0% of visits had prolonged wait times longer than 4 hours, 8.6% had prolonged LOS longer than 12 hours, and 42 revisits occurred per 1000 ED visits. Prolonged wait times were rare among other sites. However, prolonged LOS affected 425 visits (2.2%) in urban high-pediatric volume EDs, 133 (2.6%) in urban pediatric low-volume EDs, and 176 (3.1%) in rural EDs. High visit volumes were associated with increased ED revisits across sites.

Conclusions and Relevance   In this cohort study of more than 2.7 million ED visits, a pediatric viral illness surge was associated with different pediatric acute care across EDs in the state. Clinical management pathways and quality improvement efforts may more effectively mitigate dangerous clinical conditions with strong collaborative relationships across EDs and setting of care.

Emergency department (ED) operations require that staffing, facility, and equipment availability are balanced with patient needs to maintain high-quality care, especially during periods of system stress. An important component of operational planning is pediatric readiness. Where pediatric expertise and equipment are promptly available, mortality for critically ill children is reduced. 1 Respiratory conditions are among the most common potentially serious illnesses for which children present for emergency care. 2 Periods of respiratory illness surge may weaken standard ED care processes, especially for more vulnerable patients, those with complex chronic conditions, 3 or those in community or rural EDs.

Early in the COVID-19 pandemic, there was a precipitous decrease in pediatric ED visits for respiratory illness to less than 40% of baseline, 4 but this was short-lived. More recently, beginning in September 2022, pediatric ED visits in the US for respiratory concerns surged with a wave of COVID-19, influenza, and respiratory syncytial virus (RSV) infections. 5 - 7 In research among adults, health system strain during periods of increased demand for acute care during the COVID-19 pandemic has been shown to contribute to overall population-level mortality. 8 , 9 More generally, an extensive research literature has demonstrated the harmful effects of emergency department (ED) “crowding,” where available staff and space are not on hand to meet patient care demands. 10 , 11 Access to emergency care and safe clinical operations may be compromised when wait times and lengths of stay (LOS) are severely prolonged.

To date, little research has described how health system strain affects acute care for children with viral and respiratory conditions across diverse hospital-based EDs. Three accessible and patient-relevant operations metrics for ED care are ED wait times, LOS, and ED revisits following a discharge. 12 These measures represent the timeliness of care, the availability of ED and hospital-based resources, and, in the case of ED revisits, the potential accessibility of outpatient follow-up care. 13 The goal of this investigation was to describe wait times, LOS, and ED revisits for pediatric patients with acute viral and respiratory conditions across a wide range of EDs participating in a statewide quality improvement collaborative data registry, with a focus on a period of surge in pediatric illness and ED patient volumes.

This was a retrospective cohort study of patients younger than 18 years presenting to EDs participating in the Michigan Emergency Department Improvement Collaborative 14 , 15 (MEDIC) from January 1, 2021, to December 31, 2022. The study was classified as exempt by the Institutional Review Board at the University of Michigan, Ann Arbor. This study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

The MEDIC data registry includes electronic health record–extracted data elements for all ED visits among participating sites. We identified September 1 to December 31, 2022, as the time frame for focused analysis of the surge based on the rapid increase in pediatric ED visits in that period. We stratified the ED site types as children’s hospitals, urban EDs with high pediatric volume (pediatric visits were ≥10% of the total visits), urban EDs with low pediatric volume (pediatric visits were <10% of the total visits), and rural community EDs, based on the premise that ED operations and capacity to respond to pediatric surge are likely to vary significantly among these groups. Urban-rural designations were defined per standardized Rural-Urban Commuting Area codes as implemented in prior US research on locations of EDs. 16

We included ED visits based on review of all chief problems and diagnosis codes identified as likely attributable to the viral and respiratory illness surge in 3 steps. First, we included ED visits with a chief complaint for fever and/or respiratory signs and symptoms (eg, cough, rhinorrhea, shortness of breath). Second, we included visits with an International Classification of Diseases, Tenth Revision, Clinical Modification ( ICD-10-CM ), diagnosis code (primary diagnosis or secondary diagnoses) for an infectious respiratory condition using the Healthcare Cost and Utilization Project Clinical Classification Software Revised. 17 These codes are broadly inclusive of common pediatric respiratory conditions such as asthma, croup, bronchiolitis, pneumonia, and respiratory failure. Third, we included ED visits with any ICD-10-CM code consistent with an acute viral syndrome, including syndromic codes (such as R06.02 [shortness of breath] and R50.9 [fever, unspecified]), as well as those specific to a particular viral pathogen (such as Z20.822 [contact with and suspected exposure to COVID-19] and J12.2 [ parainfluenzavirus pneumonia]). eTables 1 and 2 in Supplement 1 detail the most common chief problems and ICD-10-CM codes used to define the cohort of pediatric respiratory and viral ED visits for analysis.

Outcomes included median (IQR) ED wait times and LOS reported in hours, count and proportion of ED visits with prolonged wait times (>4 hours) and LOS (>12 hours), as well as rate of ED discharge with subsequent return within 72 hours (per 1000 ED visits). Wait time was defined as the first available time stamp for the encounter (arrival/triage) to the time a clinician was assigned; LOS was defined as the first available time stamp for the encounter to ED departure time stamp. We chose to dichotomize outcomes for prolonged wait times and LOS because of observed small changes in medians over time and because adverse consequences for patients are likely to be concentrated among those at these extremes (eFigures 1 and 2 in Supplement 1 ). The 4- and 12-hour thresholds were specified after review of the distribution of these outcomes, to target relatively face-valid time frames for problematic waits and LOS. For a small number of visits at several sites, patients are placed in ED observation care, as described in the Results section. The MEDIC data registry does not allow us to distinguish the time when ED observation care is initiated. This means that for the small number of cases where observation care took place, LOS is total time in ED inclusive of initial ED care and observation care.

We report sociodemographic characteristics, acuity (emergency severity index [ESI] score, ranging from 1 to 5, with higher scores indicating lower acuity), diagnoses, and disposition among sample ED visits. We included demographic variables for age, sex, and race and ethnicity. Age was categorized as younger than 4 weeks, 4 weeks to 3 months, 4 to 23 months, 2 to 4 years, 5 to 11 years, and 12 to 17 years based on existing guidelines for the clinical care of children with conditions such as fever and asthma. 18 , 19 Data for patient sex were drawn from electronic health records across sites, and information clarifying this variable vs patient gender or gender identity were not readily available. Where available, race and ethnicity were categorized in accordance with best practices in health services research. 20 However, race and ethnicity data collection are both limited and with likely heterogeneous reporting mechanisms across participating EDs and in the MEDIC data registry. Race data were categorized as American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, White, more than 1 race, and other race or ethnicity. Ethnicity data were categorized as Hispanic or Latino and non-Hispanic or non-Latino.

To place the visit volumes during the surge from September 1 to December 31, 2022, in the context of recent trends in ED visit rates, weekly visit counts were plotted from January 1, 2021, through December 31, 2022, and we compared total visits during the chosen surge period (September 1 to December 31, 2022) with those of the preceding 4-month period (May 1 to August 31, 2022) as well as the same months in the preceding year (September 1 to December 31, 2021).

To examine the association between shifting pediatric viral and respiratory visit volumes and our outcomes, we created a z score for daily visits for these patients at each site across the entire 2-year study period. We report odds ratios (ORs) for ED visits’ likelihood of resulting in prolonged wait times (>4 hours), prolonged LOS (>12 hours), and ED revisit after discharge (within 72 hours) across ED types according to each site’s daily pediatric viral and respiratory visits z score (<1 SD above the 2-year study period mean visit volume, labeled moderate or low volume; 1-2 SDs above the mean, high volume; and >2 SDs above the mean, highest volume).

We then focused on the identified surge period (September 1 to December 31, 2022), to address how wait times, LOS, and revisits varied across different sites during the surge. We tabulated monthly outcomes for each of the 4 months in the period and compared odds of outcomes across site types. Urban community EDs with 10% or greater pediatric volume were used as the reference category for those comparisons, given that these EDs likely represent the plurality of ED visits for children nationwide. 21 Given the likely significant case-mix variation among EDs, ORs are reported as unadjusted as well as adjusted for age, sex, race and ethnicity, ESI, and presence of complex chronic conditions (according to the Feudtner classification system 22 ).

Data cleaning and tabulations were performed in R, version 4.1.2 (R Project for Statistical Computing). Statistical modeling was performed in Stata, version 18 (StataCorp LLC). Two-sided P < .05 indicated statistical significance.

A total of 2 761 361 total adult and pediatric ED visits across 25 EDs in 2021 and 2022 were retrieved. The sample included 3 pediatric referral hospitals, 9 urban sites with high pediatric volume (≥10%), 7 urban sites with low pediatric volume (<10%), and 6 rural community EDs (eTable 3 in Supplement 1 ). There were 301 688 total pediatric viral and respiratory visits (inclusive of 53.1% of all pediatric visits and 10.9% of total ED visits in the study). The most common diagnoses in the cohort (eTable 2 in Supplement 1 ) were for signs and symptoms of upper respiratory tract infection (40 181 [13.3%]), fever, unspecified (24 011 [8.0%]), and COVID-19 (13 985 [4.6%]). eTables 4 and 5 in Supplement 1 list available sociodemographic and visit characteristics across ED types (52.4% male and 47.6% female patients; most patients [28.3%] aged 4-23 months). In terms of race, 0.03% of patients were American Indian or Alaska Native, 1.0% were Asian, 30.9% were Black, 0.1% were Native Hawaiian or Other Pacific Islander, 40.4% were White, 2.4% were more than 1 race, and 19.7% were of other race. In terms of ethnicity, 9.7% were Hispanic or Latino and 90.0% were non-Hispanic or non-Latino. Children’s hospitals cared for a larger proportion of Black patients, patients with higher-acuity and more complex chronic conditions, and patients with higher admission rates. Conversely, rural sites treated more White patients with lower-acuity conditions and higher discharge rates. Beginning in September 2022, visits for viral and respiratory illnesses began to rise and peaked from November to December 2022. During that period and across ED types, there were a total of 74 282 such visits, an increase of 71.8% compared with the 4 preceding months and 15.7% more than during the same period in 2021 ( Figure ). The surge period from September to December 2022 comprised all the highest-volume days (>2 SDs above the 2-year study period mean) for visits for pediatric viral and respiratory illnesses.

Daily visit volumes were variably associated with wait times, LOS, and ED revisits across site types ( Table 1 ). For example, compared with moderate- or low-volume days at children’s hospitals, highest-volume days were associated with increased wait times longer than 4 hours (OR, 4.09 [95% CI, 3.79-4.42]), LOS longer than 12 hours (OR, 1.37 [95% CI, 1.26-1.48]), and ED revisits (OR, 1.40 [95% CI, 1.28-1.53]). In contrast, daily pediatric viral and respiratory visit volumes were not consistently associated with prolonged wait times at other sites. Rural EDs, though, had greater LOS on high- (OR, 1.47 [95% CI, 1.15-1.88]) and highest-volume days (OR, 2.06 [95% CI, 1.59-2.64]), despite a lack of association on these measures for other community EDs. Prolonged LOS was generally associated with higher-acuity visits, and more than 200 ED visits in the sample resulting in transfer had an LOS greater than 12 hours (eTable 6 in Supplement 1 ). Across site types, highest-volume days were associated with greater ED revisits within 72 hours as compared with low- or moderate-volume days, though ORs were not statistically significant in the case of urban, low pediatric volume sites. A minority of ED revisits (from as low as 9.7% at rural sites to as high as 26.2% at children’s hospitals) resulted in hospitalization (eTable 7 in Supplement 1 ).

Daily visit volumes rose and peaked in the identified surge period from September 1 to December 31, 2022. There was considerable variation in wait times, LOS, and ED revisit rates across site types during that period ( Table 2 ). While median wait times were generally less than 1 hour across EDs, wait times greater than 4 hours were common at children’s hospitals (occurring in 3504 visits [8.0%] during the surge period) and rare at other sites. An LOS longer than 12 hours was also more common at children’s hospitals (occurring in 3789 visits [8.6%]) compared with urban sites with low pediatric volume (133 [2.6%]), urban sites with high pediatric volume (425 [2.2%]), and rural EDs (176 [3.1%]). In addition, at their peak volume in November, 84 of 1658 rural ED visits (5.1%) exhibited LOS longer than 12 hours. After adjusting for age, sex, race and ethnicity, ESI acuity, primary diagnosis, and complex chronic conditions (adjusted OR [AOR]), the odds of wait times longer than 4 hours and LOS longer than 12 hours for ED visits were greater during the surge at children’s hospitals (AORs, 51.43 [95% CI, 37.76-70.04] and 3.82 [95% CI, 3.44-4.26], respectively), urban sites with low pediatric volume (AORs, 10.24 [95% CI, 7.13-14.71] and 1.02 [95% CI, 0.82-1.25], respectively), and rural EDs (AORs, 5.17 [95% CI, 3.42-7.81] and 1.85 [95% CI, 1.53-2.22], respectively) compared with urban sites with high pediatric volume ( Table 3 ). Of the 4523 total visits with LOS longer than 12 hours during the identified surge period ( Table 2 ), 78 (1.7%) at 5 EDs in the sample included ED observation care. Emergency department revisit rates by site type and month varied from 16 to 66 per 1000 visits (eg, 42 per 1000 visits at children’s hospitals) and were highest at rural sites.

While increases in pediatric volume were universal across this diverse group of 25 EDs participating in MEDIC beginning September 1, 2022, the association of high visit volumes with prolonged wait times, prolonged LOS, and ED revisits were heterogeneous. Children’s hospitals exhibited stronger associations between visit volumes and these measures and with greater overall burden of operational strain. Emergency department visits during the identified surge period were 53 times more likely to have prolonged wait times greater than 4 hours at children’s hospitals compared with EDs with high pediatric volume. Case-mix adjustments available did not mitigate these differences between types of EDs, suggesting that otherwise similar patients can expect longer waits at children’s hospitals than at other EDs. Because visits for pediatric viral and respiratory illness comprise much of their overall care, children’s hospitals may be especially susceptible to viral illness surges among children, while ED operations at other sites may not be as sensitive to shifting pediatric care demands. Insofar as children’s hospitals are responsible for a growing proportion of inpatient care in the state, including accepting transfers from outlying sites, this may explain the bottleneck affecting wait times and LOS at those sites. At the same time pediatric volumes are growing, other sites may be experiencing decline or stable ED volumes for adult patients, permitting some flexibility to manage a surge in pediatric ED visits. In addition, ED observation care does not appear to significantly mitigate the finding of prolonged LOS, involved in only 1.7% of the ED visits with LOS longer than 12 hours during the identified surge period.

The mission of the MEDIC project is to improve ED care quality through a learning health system model. 23 MEDIC partners with EDs within the network to support quality improvement through techniques such as audit and feedback measurement and reporting, support of evidence translation to practice change, and knowledge generation and dissemination. At the height of the 2022 respiratory viral surge period and as part of the All in for Kids campaign, the MEDIC coordinating center organized a virtual town hall with representatives from across the state to share operational challenges and identify approaches to mitigate them. 24 Participants described shortages of beds and nursing expertise, insufficient pediatric readiness, and suboptimal coordination between small EDs and transfer centers 25 as specific areas in need of support.

The American Academy of Pediatrics recently released a technical report in response to unprecedented pediatric patient volumes in late 2022, outlining steps that EDs can take to mitigate the deleterious effects of ED crowding. 26 The report cites the need for standardized clinical management pathways, quality measurement development, and financial incentives such as pay-for-performance to ensure that children in children’s hospitals and community EDs alike receive timely and high-quality care. We observe that children’s hospitals are much more likely to exhibit large proportions of patients with prolonged wait times and LOS, which may contribute to dangerous conditions across the state if critically ill children requiring transfer at other sites are also affected. Concerningly, children in other EDs, especially in rural locations, were also affected by prolonged LOS in excess of 12 hours, and this may partially represent a referral network–wide capacity constraint. In addition, highest-volume days for ED visits were consistently associated with greater risk of return visits, which might reflect difficulty accessing outpatient follow-up care during surge periods, a higher threshold to admit patients when bed availability is limited, or lower-quality care in the ED setting. An essential feature of future pediatric readiness and surge preparedness efforts should be collaborative relationships across children’s hospitals, community EDs, rural sites, and outpatient pediatrics practices, as this will enhance the effectiveness of clinical management pathways and quality measures cited in the technical report on crowding.

The American Academy of Pediatrics report also outlines the influence of sociodemographic and community factors on both where crowding occurs and whom it adversely affects. Existing literature 27 has demonstrated differences in wait times nationwide by race and ethnicity prior to the COVID-19 pandemic. Though limited by the absence of complete and high-quality data on race and ethnicity, we find that larger children’s hospital EDs are most adversely associated with crowding. That sites with greater strain may also care for a greater proportion of patients from racial and ethnic minority communities may be a feature of structural racism. That said, a nuanced interpretation of differences between sites must address both the contextual as well as compositional effects. 28 Contextual effects, such as operational conditions, staffing and space availability, and underlying payer mix, may represent health policy and financing mechanisms requiring reform. Compositional effects, such as differences in underlying medical complexity of patients or severity of illness among patients presenting to children’s hospitals as opposed to community EDs, may represent more upstream drivers of poor health status. Importantly, crowded conditions may also contribute directly to clinician biases and decision-making that exacerbate disparities in care. 29 , 30 Notably, our case-mix adjustments do not explain differences in rates of prolonged wait times, LOS, and ED revisits between children’s hospitals and other sites. Attention to differential effects of crowding across and within EDs is essential to mitigate harms during future periods of system strain.

This study has several important limitations. First, this was not a comprehensive assessment of all EDs in the State of Michigan, so our results may not be generalizable. A more detailed description of sites’ individual capacities, including pediatric readiness score or drive time to the closest pediatric intensive care unit, is not yet available in the MEDIC data registry. That said, we provide some context for the sites we assessed, including urban-rural designation, pediatric volume, hospitalization, and pediatric intensive care unit availability (eTable 3 in Supplement 1 ). Further, the MEDIC registry includes all of the dedicated stand-alone children’s hospitals in Michigan in addition to other EDs providing care to children in urban and rural areas. Second, differences in wait times, LOS, and revisits may reflect differences in patient case mix between EDs that we were not able to explore. Prolonged wait times and LOS are rare, especially at nonpediatric referral hospital sites, limiting our ability to adjust for differences in age, acuity, and chief complaints. For 1.7% of ED visits with prolonged LOS longer than 12 hours, ED observation care was documented. Thus, for those visits, prolonged LOS does not necessarily reflect problematic or strained care processes. Sites vary considerably in baseline operational characteristics, and our results should not be construed to imply that the surge explains baseline differences in prolonged wait times and LOS across site types. Third, while we attempted to isolate a cohort of acute viral and respiratory presentations, some patients may have presented for other reasons that resulted in prolonged wait times, prolonged LOS, or risk of ED revisit unrelated to the operational state of the ED (eg, mental health visits 31 ). Fourth, while wait times, LOS, and revisits are important for patient experience and may be useful proxies for potentially dangerous clinical conditions, our work lacks other specific measures of health system strain, including total hospital occupancy or outcome measures such as mortality (rare in pediatric populations). Future work to follow up a cohort of pediatric patients over time, especially throughout their hospital stays for those requiring admission, will be essential.

Our findings notwithstanding, there is a paucity of data available to describe the differential effects of system strain across hospitals. Future pandemics, epidemics, and other disasters are likely to precipitate similar surges in acute care demands, and existing literature has clearly demonstrated the harms of ED crowding. 11 Finally, race and ethnicity data in the MEDIC data registry are collected according to local practices without standardization across the network and with high rates of missingness. This limited our ability to address disparities for racial and ethnic minority groups within or across EDs. Nevertheless, our finding that different hospitals experience differential associations with prolonged wait times and LOS are consistent with ED crowding as a potential lever driving health care disparities. 32

In this cohort study of more than 2.7 million ED visits in Michigan, a pediatric viral illness surge was associated with different pediatric acute care across EDs in the state. Associations between visit volumes and the incidence of prolonged wait times, prolonged LOS, and ED revisits were heterogeneous. Future surges in acute care demand may have similarly differential impacts. Clinical management pathways and quality improvement efforts are more likely to effectively mitigate dangerous clinical conditions with strong collaborative relationships across different EDs and crossing settings of care. Policy makers and health system leaders should pursue a financial and operational model of pediatric acute care that rewards both pediatric readiness and surge preparedness to ensure that all children receive the best possible care.

Accepted for Publication: October 26, 2023

Published: December 7, 2023. doi:10.1001/jamanetworkopen.2023.46769

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Janke AT et al. JAMA Network Open .

Corresponding Author: Alexander T. Janke, MD, MHS, National Clinician Scholars Program, Veterans Affairs Ann Arbor Healthcare System, University of Michigan, 2800 Plymouth Rd, North Campus Research Complex, Bldg 16, Ann Arbor, MI 48109 ( [email protected] ).

Author Contributions: Dr Janke had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Janke, Fung, Macy, Kocher.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Janke, Fung.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Janke, Mangus, Fung, Kamdar.

Obtained funding: Kocher.

Administrative, technical, or material support: Fung, Nypaver, Kocher.

Supervision: Macy, Nypaver, Kocher.

Conflict of Interest Disclosures: Mr Kamdar reported receiving grant funding from Stanford University, The University of North Carolina at Chapel Hill, and University of New Mexico outside the submitted work. Dr Macy reported receiving salary support for involvement in Michigan Emergency Department Improvement Collaborative (MEDIC) from Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network (BCN) as a part of the BCBSM Value Partnerships program. Dr Nypaver reported receiving grant funding from BCBSM/BCN to support MEDIC during the conduct of the study. Dr Kocher reported receiving grant funding from BCBSM/BCN to support MEDIC during the conduct of the study. No other disclosures were reported.

Funding/Support: Support for MEDIC is provided by BCBSM/BCN as a part of the BCBSM Value Partnerships program. Dr Janke is supported by the Department of Veterans Affairs Office of Academic Affiliations.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: Although BCBSM and MEDIC work collaboratively, the opinions, beliefs, and viewpoints expressed by authors affiliated with MEDIC do not necessarily reflect the opinions, beliefs, and viewpoints of BCBSM or any of its employees. The opinions expressed here do not necessarily represent those of the US government.

Data Sharing Statement: See Supplement 2 .

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The Most Common Pediatric Emergencies

Did you know nearly a third of emergency room visits are due to pediatric emergencies? Sick and injured children are a unique population that requires special care. There are many differences between treating adults and providing emergency medical care for children.

The signs and symptoms in children tend to be subtle and normal values for pulse, breathing, and other vital signs change as a child grows. The doctor needs specialized knowledge of pediatrics to determine if there really is a problem and how to treat it.

Most emergencies fall into the general categories of breathing trouble, upset stomachs, injuries, and infections. Children get sick, are exposed to environmental dangers (like drowning or poisons), or may have chronic conditions that put them at higher risk of any of these problems.

Emergency rooms with qualified pediatric healthcare providers take care of all of these problems as well as meet the challenge of keeping Mom and Dad (or another caregiver) as calm and informed as possible. 

Here is when to go to the ER with your child, how doctors and nurses approach diagnosing and treating your child, and the most common issues seen for emergency children’s treatment.

Trust Your Instincts: When to Go to the ER With Your Child

You know your child best. As they grow, children show parents how they are feeling with their behavior. Even those who can’t talk yet or describe the problem can tell you something isn’t right.

Take your child to the emergency room if you notice:

• Symptoms or complaints of severe pain
• Trouble breathing – wheezing, flaring the nostrils, or straining other muscles to breathe
• Ongoing or excessive diarrhea or vomiting
• Injuries from a fall, accident, or while playing sports
• Few or no bowel movements over several days
• Painful bowel movements
• Fever that doesn’t go down with medicine like Tylenol or Ibuprofen
• Exposure to toxic substances like poisons, cleaning supplies, and other non-food items
• Signs of dehydration like sunken-looking eyes, few to no tears when crying, dry or sticky mouth, fewer diapers than normal

If you think your child needs emergency treatment, you are probably right. Even if it turns out to be something minor, it’s best to be careful.

What Is the First Thing the Doctor Will Do?

The first thing the emergency pediatrician does is evaluate or examine the child to get an idea of the problem.

Next, the doctor follows an ABCDE assessment . This means checking the child’s:

• A irway for obstructions
• B reathing ability and amount of difficulty
• C irculation to ensure blood is flowing where it needs to be
• D isability to determine how much the problem affects the child’s ability to move and think
• E xposure to poisons, toxins, plants, medicines, or other substances that could cause a problem

Then the doctor will ask a series of questions to find out whether your child has been running a fever, vomiting, wheezing, and other signs of illness before you came to the ER. The pediatrician or nurse will also ask about allergies to medications or other substances and any medications the child takes regularly.

Just like a hospital, Family First ER is open 24 hours a day, every day of the year. See more details on the range of emergency services we offer.

8 Common Pediatric Emergencies

Respiratory distress – trouble breathing.

If a child runs a high fever or has a chronic illness involving the lungs, respiratory distress is a common symptom. Seizures can also cause trouble breathing. 

Common childhood illnesses that include respiratory distress include :

• Bronchiolitis 

Common signs of respiratory distress include:

• Rapid breathing
• Nasal flaring (flaring the nostrils)
• Using more muscles to try to breathe, like straining the abdominal or neck muscles
• Grunting, wheezing, and other abnormal breath sounds
• Lethargy or irritability
• Sinking of the chest
• Sitting with hands on knees or another surface to try to relieve distress

You can take your child to the emergency room for any type of breathing trouble, but please call 911 if your child is not breathing.

Trauma means injury from a serious accident like being in a car accident, falling off a bike (or a roof), or injuries caused by playing sports.

From deep cuts (lacerations) to sprained or broken bones, from concussions to other types of head injury, trauma is a common reason for an emergency room visit, especially if it is severe.

Digestive (Tummy) Issues

So many things can cause tummy problems in infants and children. Infections with a virus, bacteria, or fungus can cause vomiting, diarrhea, and stomach pain. It may also occur due to an undiagnosed food allergy or sensitivity. (In some cases, a food allergy can also cause respiratory distress.)

Another cause of digestive issues is intestinal obstruction. When something is blocking the intestines, the body cannot continue digestion or get rid of waste. Hepatitis is also considered a digestive issue since it involves the liver, a major organ that helps the body remove toxins.

Bacteria, viruses, and fungi can do more than cause tummy problems. They can infect cuts, cause ear or respiratory infections, meningitis, encephalitis, endocarditis, and childhood diseases like Whooping Cough.

Skin Conditions

Sometimes skin problems need emergency treatment. Issues include pain, itching, inflammation, redness, and other discomforts. A skin condition can come from genetic factors, too. 

Viruses and environmental exposure (poison ivy, anyone?) can cause skin conditions such as:

• Erythema (redness)
• Chickenpox (viral infection with Herpes zoster )
• Pustules (small fluid-filled bumps on the skin)

Scratching at skin conditions like a rash can create the conditions for another infection to enter any open skin.

Lots of things cause pain, and small children may not be able to tell you much about it other than it hurts.

Our pediatric emergency room doctors treat abdominal pain, chest pain, acute (severe and sudden) headache, and orthopedic (foot) pain.

Environmental Injuries

Environmental injuries include:

• Smoke inhalation
• Anaphylaxis 
• Hypothermia (critically reduce body temperature)
• Heatstroke 
• Dehydration 

Fire, water submersion, and other environmental factors can cause a host of problems.

Chronic Conditions

Children and babies with chronic conditions often require visits to the emergency room when their illness creates sudden and severe problems. These conditions include:

• Congenital heart problems (heart problems from birth)
• Endocrine or metabolic disorders like diabetes
• Hematological or blood disorders like sickle cell anemia
• Neurological (brain) disorders
• Oncologic (cancer) issues

Chronic health conditions increase the probability the child will develop problems requiring emergency treatment.

Visit Family First ER

Family First ER has experienced pediatricians on staff, ready to diagnose and treat infants, toddlers, children, and teens for any illness or injury they may have.

Don’t hesitate to bring your child to see us or call if you have questions. We are here to serve you.

Choose one of our locations

• 346-437-9888

Urgent care vs emergency room: What's the difference?

It’s Saturday, and the cold you’ve been nursing for the past few days seems to be getting worse. You’ve vomited once and have a fever. Should you head to a hospital emergency room or an urgent care clinic?

Learn more about our urgent care Learn more about our ER

If you’ve ever wondered whether to go to an ER or an urgent care clinic, you’re not alone. As physicians, we’re often asked by family, friends and patients if their symptoms warrant an ER visit, a trip to an urgent care clinic, a call to their primary care doctor or simply management at home.

If you are experiencing mild symptoms , such as mild aches and pains, a mild cough, etc., that could be caused by the flu, COVID-19, RSV  or hundreds of other viruses, consider “doing what your mom used to tell you” — rest, drink plenty of fluids, take over-the-counter medications like Tylenol, if needed, and monitor your symptoms.

If your symptoms don't improve over time, or if they worsen, calling your primary care physician  may be beneficial. Many primary care physicians are now offering virtual visits and can assess patients by a phone or video call fairly quickly.

However, if your symptoms are more severe and can’t wait for an appointment with your doctor, consider your other options for care.

Urgent Care

Unless a condition is life-threatening, a trip to urgent care is generally a better use of a patient’s time and resources to treat injuries, fevers, infections and other ailments.

Urgent care centers often have far shorter wait times than the ER and cost less than a traditional hospital emergency room visit. And many, like our UChicago Medicine Dearborn Station ,  UChicago Medicine Medical Group - Homewood  and UChicago Medicine River East  urgent care centers, offer convenient benefits such as walk-in appointments and on-site x-ray.

There are a variety of conditions treated at our urgent care centers , but common reasons to visit one include:

• If you are experiencing mild to moderate cold symptoms and not sure whether it is flu, COVID-19 or RSV.  
• If you have a sore throat and are concerned it is viral or strep throat.
• If your virus or cold symptoms developed into infections, like ear infections or pneumonia, and may require antibiotics.

Our urgent care clinics have board-certified physicians on staff who can test for and treat these conditions and much more. We treat both adult and pediatric  patients and are available 7 days a week, from 8 a.m. to 8 p.m. during weekdays and 8 a.m. to 4 p.m. on weekends and holidays.

If necessary, urgent care providers can also connect you with a higher level of care.

Emergency Room

You should call 911 or come right to the emergency room if you’re systemically sick. That’s when an illness affects your entire body, and you have severe pain or sudden onset of severe symptoms, a fever that won’t break, or “something doesn’t work,” like you’re unable to move an arm or leg or breathe normally. This includes:

• If a person has a severe injury or allergic reaction.
• If they pass out or experience any signs of a possible stroke or signs of a heart attack.

While you or the victim may have a hospital of choice, an emergency may warrant going to the nearest emergency location for immediate treatment. With their connection to hospitals for seamless admittance and advanced level of technology, ERs are the best place for actual emergencies.

Should you call 911 or go to the hospital emergency room?

The American College of Emergency Physicians (ACEP) has useful guidance on when to call 911, but common reasons include:

• The condition is life-threatening and requires attention as soon as possible. 
• You are unable to move yourself or the victim without causing harm or further damage.
• You are physically or emotionally unable to drive or be transported to a hospital ER. 

Urgent Aid for Lower-Level Emergencies

If you’re in the Southland, UChicago Medicine Ingalls Memorial offers an additional option to consider before heading to the ER. In our south suburban urgent aid centers , physicians provide ER-level care for lower-level emergencies — injuries, viruses and other illnesses — 24 hours a day, every day in an urgent care-like setting.

If a stable patient needs higher-level imaging such as an ultrasound or CT scan, urgent aids may be a better fit than an urgent care clinic.

The cost of an urgent aid visit is the same as the emergency department of Ingalls Memorial for the same level of care. The co-pay for emergency services will apply to your urgent aid visit, which may be higher than the co-pay for services provided by urgent care centers that are not part of a hospital’s emergency department.

Anwar Isabell, MD, is a UChicago Medicine Medical Group provider. UChicago Medicine Medical Group is comprised of UCM Care Network Medical Group, Inc. and Primary Healthcare Associates, S.C. UChicago Medicine Medical Group providers are not employees or agents of The University of Chicago Medical Center, The University of Chicago, or UChicago Medicine Ingalls Memorial.

Anwar Isabell, MD

Board-certified family medicine physician, Anwar Isabell, MD, specializes in care for the whole family.

Daniel Bickley, MD

Daniel Bickley, MD is the Interim Medical Director of the Adult Emergency Department at the University of Chicago Medicine.

Where Should I Go for Care Today?

You never know when a sudden injury or illness may happen. That's why it's so important to be prepared and know what steps you can take as soon as symptoms appear. Click below to learn more about the best times to visit primary care, urgent care or the emergency department.

When should I contact my primary care doctor?

Your regular doctor is the best person to call for minor health issues because they know your medical history.

When should I go to urgent care?

When you need care right away, but the illness or injury isn’t considered life-threatening, visit an urgent care clinic.

When should I seek emergency care?

If you have severe symptoms that could be life-threatening, call 911 or go to the emergency room right away.

StarTribune

One day in the frantic life of a children's minnesota emergency room nurse.

It's not exactly a superpower, but nurse Joe Schwartz can tell with his nose what is causing his patient in the Children's hospital emergency department in St. Paul to look so weak, so bony thin.

When 10-year-old Juliana Jones says hello, Schwartz smells a sharp odor, like fruit gone bad, on her breath. It suggests acid buildup in her body, which likely means a dangerous complication from undiagnosed diabetes.

"My sniffer is pretty good," he says. "It's where I think we are headed."

Work in the ER is like that, drawing on basic senses beyond medical skills as nurses confront infections, trauma, mental illnesses and chronic diseases. The jack-of-all-trades nature of the job, combined with the stress and occasional conflicts with distraught parents or delirious patients, makes it one of the hardest to fill in Minnesota health care.

Children's launched a campaign to hire 176 more nurses by fall, because parents are bringing more and more children to its hospitals, but it fell behind on recruiting for its emergency departments in St. Paul and Minneapolis. The pediatric provider offered a behind-the-scenes look at Schwartz, a particularly versatile nurse, earlier this spring to spark interest in this branch of nursing.

"They have to be really experts in all areas because they see everything," says Yinka Ajose, a Children's clinical director leading the hiring campaign.

Schwartz, 27, was destined for pediatrics as the son of a Children's Minneapolis ER nurse. He worked in child care and children's programming at a fitness club before joining Children's as a clinical assistant and finishing nursing school on the side.

"[Helping kids has] always been a passion of mine," he says.

It's 11 a.m. when Schwartz wheels Juliana to room 4.

It's been a manageable morning since he started his 12-hour shift at 7 a.m. with a sip of his ultra-caffeinated drink. "I don't think it does anything for me anymore," Schwartz laments.

First comes the pale 20-year-old in room 18 who threw up all night after eating seven pot-stickers at the San Francisco airport. Then comes the 5-year-old sporting leopard-print pajamas and clutching a stuffed hedgehog in room 22. She is suffering the double insults of strep and influenza.

"We've been seeing that a lot lately," he says.

Then comes the rambunctious 6-year-old with strep who can't lie still. Schwartz guesses he is still infected because he skipped antibiotic doses and is simply restless after being stuck in bed for days. His mother worries he might have PANDAS, because she read how the mysterious condition causes bizarre behavior after infections.

PANDAS is rare, but listening and ruling out possibilities is part of Schwartz's job. He gets down on one knee to look at eye level at his patient.

"He's been screened for ADHD," his mother insists, "but nothing like this. This is different."

The challenge by lunchtime is plain for the St. Paul ER. Eleven nursing shifts on a staffing sheet are highlighted with yellow marker, meaning they were open at the start of the day. Six remain unfilled. The number of patients in the ER has increased from three to 18 and will soon reach 23 — with five more waiting.

Staffing gaps usually get covered last-minute by nurses willing to work overtime, administrators who are still licensed, or expensive contract nurses. Clinical assistants can cover mundane tasks as well so that short-staffed nurses can take more patients. But those stopgaps might not last, Ajose says. Children's projected last fall that it would need to increase nurse staffing by 10% in one year to keep pace with demand.

Pediatric hospitals were so underused during the pandemic that Children's put workers on extended furloughs. Some retired. Now it's under pressure, partly because general hospitals are cutting back. Mercy Hospital in Coon Rapids is one example, converting its pediatric beds for adult use.

"During COVID times, there was nobody that waited in our waiting room," Schwartz says. Now, four- to six-hour delays aren't surprising.

Juliana's arrival has created a buzz. A charge nurse takes on the case of the restless boy so Schwartz can focus on this frail girl.

Blood tests are needed urgently, Schwartz tells the upset mother. Juliana lost weight amid school stress, but the whole family is thin and her mother didn't suspect problems until her daughter threw up.

"We are worried about her," Schwartz says, "and we want to get this stuff started quicker than later."

This is the third IV line Schwartz has threaded in patients' wrists today so they can receive fluids and medicine, but none more challenging. The acid smell suggests the girl's blood is flooded with ketones, which convert fat into energy when people haven't eaten. A lack of insulin in people with diabetes tricks the liver into overwhelming the bloodstream with these acids, sometimes fatally.

Juliana's veins have receded due to dehydration and illness. Schwartz is struggling to find one to draw blood.

"What's your favorite thing to do with your kitties?" he asks as a distraction.

"Cuddle them," the girl replies.

"Oh, puppy and kitty cuddles are the best!"

Schwartz works in the ER some days but on others he is a charge nurse or trains new hires.

On this day he is shadowed by Shanna Jorgenson, who left an administrative job at a competing hospital to return to hands-on nursing. She feels the urgency and is helping, but can't find supplies Schwartz needs in an unfamiliar cart.

"It's there — the white packaging," Schwartz says, directing her to a compress. "Right, right ... Right below your hand!"

Schwartz hustles to a trauma bay to find a scanner that will analyze the acidity of his hard-won blood sample. The first scanner is out of power, so he searches for a second.

"Do you have it?" Jones' doctor asks about the result. "Still cooking?"

"Another 100 seconds," Schwartz replies.

They are concerned. This didn't happen overnight.

"She had to be losing weight for a lot longer," Schwartz says.

ED nursing can mean celebrating small successes without closure. The readout confirms the suspicion, and Juliana is prescribed insulin to undo the harmful chemical reaction in her body.

Diabetes specialists at Children's Minneapolis are ready to take over care, so medics whisk the girl back through the door she entered hours earlier.

Schwartz may not see her again, but then there's the next patient — a newborn needing X-rays to check for a bowel obstruction.

"I tell anybody who is on the outside looking in, the ER is a different beast," Schwartz says. "Ultimately you'll know that you're cut out for it by the end of your first week. Usually."

Jeremy Olson is a Pulitzer Prize-winning reporter covering health care for the Star Tribune. Trained in investigative and computer-assisted reporting, Olson has covered politics, social services, and family issues.

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Heat-Related E.R. Visits Rose in 2023, C.D.C. Study Finds

By Noah Weiland

Reporting from Washington

The rate of emergency room visits caused by heat illness increased significantly last year in large swaths of the country compared with the previous five years, according to a study published on Thursday by the Centers for Disease Control and Prevention.

The research, which analyzed visits during the warmer months of the year, offers new insight into the medical consequences of the record-breaking heat recorded across the country in 2023 as sweltering temperatures stretched late into the year.

What the Numbers Say: People in the South were especially affected by serious heat illness.

The researchers used data on emergency room visits from an electronic surveillance program used by states and the federal government to detect the spread of diseases. They compiled the number of heat-related emergency room visits in different regions of the country and compared them to data from the previous five years.

Nearly 120,000 heat-related emergency room visits were recorded in the surveillance program last year, with more than 90 percent of them occurring between May and September, the researchers found.

The highest rate of visits occurred in a region encompassing Arkansas, Louisiana, New Mexico, Oklahoma and Texas. Overall, the study also found that men and people between the ages of 18 and 64 had higher rates of visits.

How It Happens: Heat can be a silent killer, experts and health providers say.

Last year was the warmest on Earth in a century and a half, with the hottest summer on record . Climate scientists have attributed the trend in part to greenhouse gas emissions and their effects on global warming, and they have warned that the timing of a shift in tropical weather patterns last year could foreshadow an even hotter 2024.

Heat illness often occurs gradually over the course of hours, and it can cause major damage to the body’s organs . Early symptoms of heat illness can include fatigue, dehydration, nausea, headache, increased heart rate and muscle spasms.

People do not typically think of themselves as at high risk of succumbing to heat or at greater risk than they once were, causing them to underestimate how a heat wave could lead them to the emergency room, said Kristie L. Ebi, a professor at the University of Washington who is an expert on the health risks of extreme heat.

“The heat you were asked to manage 10 years ago is not the heat you’re being asked to manage today,” she said. One of the first symptoms of heat illness can be confusion, she added, making it harder for someone to respond without help from others.

What Happens Next: States and hospitals are gearing up for another summer of extreme heat.

Dr. Srikanth Paladugu, an epidemiologist at the New Mexico Department of Health, said the state had nearly 450 heat-related emergency room visits in July last year alone and over 900 between April and September, more than double the number recorded during that stretch in 2019.

In preparation for this year’s warmer months, state officials are working to coordinate cooling shelters and areas where people can be splashed by water, Dr. Paladugu said.

Dr. Aneesh Narang, an emergency medicine physician at Banner-University Medical Center in Phoenix, said he often saw roughly half a dozen heat stroke cases a day last summer, including patients with body temperatures of 106 or 107 degrees. Heat illness patients require enormous resources, he added, including ice packs, fans, misters and cooling blankets.

“There’s so much that has to happen in the first few minutes to give that patient a chance for survival,” he said.

Dr. Narang said hospital employees had already begun evaluating protocols and working to ensure that there are enough supplies to contend with the expected number of heat illness patients this year.

“Every year now we’re doing this earlier and earlier,” he said. “We know that the chances are it’s going to be the same or worse.”

Noah Weiland writes about health care for The Times. More about Noah Weiland

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Policy Statement

Recommendations for optimizing and improving care of pediatric patients with mental health emergencies, prehospital, emergency department, systems of care, future directions, conclusions, lead authors, american academy of pediatrics, committee on pediatric emergency medicine, 2020–2021, american college of emergency physicians, pediatric emergency medicine committee, 2020–2021, emergency nurses association, pediatric committee, 2023, acknowledgments, the management of children and youth with pediatric mental and behavioral health emergencies.

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Mohsen Saidinejad , Susan Duffy , Dina Wallin , Jennifer A. Hoffmann , Madeline M. Joseph , Jennifer Schieferle Uhlenbrock , Kathleen Brown , Muhammad Waseem , Sally Snow , Madeline Andrew , Alice A. Kuo , Carmen Sulton , Thomas Chun , Lois K. Lee , AMERICAN ACADEMY OF PEDIATRICS Committee on Pediatric Emergency Medicine , AMERICAN COLLEGE OF EMERGENCY PHYSICIANS Pediatric Emergency Medicine Committee , EMERGENCY NURSES ASSOCIATION Pediatric Committee; The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies. Pediatrics September 2023; 152 (3): e2023063255. 10.1542/peds.2023-063255

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Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure; challenges with timely access to a mental health professional; the nature of a busy ED environment; and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affect patient care and ED operations. Strategies to improve care for MBH emergencies, including systems-level coordination of care, are therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

Emergency department (ED) visits by children and youth with mental and behavioral health (MBH) emergencies in the United States have been increasing over the last decade. 1   At the same time, there has been an increased prevalence of depression and suicide in pediatrics, which, for the purposes of this statement, refers to children, adolescents, and young adults. 2 , 3   In response to this, the American Academy of Pediatrics and the American Foundation for Suicide Prevention created “Suicide: Blueprint for Youth Suicide Prevention” to be a resource for health professionals caring for youth at risk for suicide. 4   Racial disparities exist in mental health, with increased rates of suicide in Black school-aged children. 5 – 7   In a study analyzing suicide rates in US youth from 2001 to 2015 among children 5 to 12 years old, the suicide rate was approximately two times higher for Black children compared with white children. 8   Since 2010, there have been increased rates of Black high school students with suicide attempts and injury after suicide attempt in the United States. 7   Overall, American Indian/Alaska Native high school students have the highest rates of suicide and suicidal ideation.

Acknowledging these inequities in MBH outcomes is an essential part of efforts toward behavioral health equity. The Substance Abuse and Mental Health Services Administration defines behavioral health equity as “the right to access quality health care for all populations regardless of the individual’s race, ethnicity, gender, socioeconomic status, sexual orientation, or geographical location. This includes access to prevention, treatment, and recovery services for mental and substance use disorders.” 9  

For children and youth with MBH conditions, there are often limited resources in the community 10 , 11   and on the institutional level (prehospital to ED to inpatient) to provide optimal care. 12   As a result, EDs have become a critical access point and safety net for those requiring acute and subacute MBH care. 13   There are also disparities in access to care based on race, ethnicity, insurance status, gender identity, language preference, and the geographic location of mental health specialists and inpatient psychiatric units. 14 – 16   In addition, there may be patient and family barriers to obtaining care, including the potential stigma of a mental health disorder diagnosis and treatment. 17   Models of community-based care to triage and manage acute MBH emergencies can be considered to broaden resources to care for these patients. 18 , 19  

In addition to these challenges, EDs have a wide variation in their capability to care for pediatric patients with MBH conditions. 20   Physicians, physician assistants (PAs), and nurse practitioners (NPs) working in EDs may experience challenges caring for pediatric patients’ MBH conditions. 21 , 22   Children and youth with intellectual disabilities, autism spectrum disorders, and behavioral dysregulation 23 , 24   ; immigrant children and those with specific cultural and language preferences 14   ; children in the child welfare system; youth in the juvenile justice system; and lesbian, gay, bisexual, queer, transgender, or questioning (LGBQT+) youth may have additional challenges, which need to be addressed. 25   Because of the diversity of the populations and the high prevalence of trauma and adversity among ED patients, organizations/ED leadership should provide resources for physicians, PAs, NPs, and nurses about trauma-informed relational care as a universal approach to care. 26  

There is often inconsistent screening for self-harm risks and substance use in patients presenting for both mental health concerns and other complaints. 27   Furthermore, pediatric patients with mental health conditions may experience prolonged ED lengths of stay while awaiting appropriate placement for a higher level of psychiatric care (eg, inpatient psychiatric unit, community-based acute treatment). 28 , 29   There are also challenges in organizing outpatient mental health care after ED discharge. The ultimate goal in the ED is to provide optimal and equitable care for children and youth with MBH emergencies. This policy statement aims to provide guidance on evidence-based best practices with resources and references ( Table 1 ) to emergency physicians, PAs, and NPs for the management of MBH emergencies in children and youth.

Strategies and Resources for EDs, Health Systems, and Communities in the Management of Children and Youth Presenting With Mental and Behavioral Health Emergencies

Diversion refers to a temporary closure of EMS transport to an ED.

Develop ED facility transfer protocols involving emergency medical services (EMS) for children, such as appropriate referrals to psychiatric crisis units, within psychiatric facilities or community mental health centers where available (eg, Pittsburgh, 30   San Francisco 31   ). These centers could provide short-term stabilization and referrals (eg, Northwell System 32   ).

Develop telehealth emergency psychiatric medical control (via EMS and schools) to identify and divert low-acuity patients to facilities equipped to manage MBH conditions.

Activate existing mental health mobile crisis teams to be able respond to schools, physicians’ offices, and homes (eg, South Carolina, 33   Georgia 34   ).

Provide resources for prehospital personnel in acute management of pediatric MBH emergencies.

Advocate for the implementation of crisis response teams as an alternative to having law enforcement respond to an MBH emergency in the community. Unnecessary contact with law enforcement should be limited or avoided, 35   if possible, during MBH emergencies, because the presence of trained individuals who can provide trauma-informed relational care is recommended, if available. 26  

Provide resources for ED staff related to recognition and provision of initial care to children and youth with potentially increased risks of MBH concerns including LGBQT+ youth; victims of maltreatment, abuse, or violence, including physical trauma, mass casualty incidents, and disasters; and those with substance use-related problems (eg, acute intoxication, overdose), preexisting conditions (eg, autism spectrum disorder, developmental delay, intellectual disability), posttraumatic stress, depression, children in the child welfare system, youth in the juvenile justice system, and suicidality.

Explore development of expanding telehealth consultations (telepsychiatry), particularly in resource-limited areas, or during pandemics and disease outbreaks such as coronavirus disease 2019, including provision for documentation, compensation for such services, and considering best practices for pricing (ie, payment bundled for multiple consults for ED patient with prolonged length of stay). Access to broadband internet for telehealth services must also be considered. In addition, strategies to improve mental health specialist continuity of care for the same patient during the same encounter should be developed.

Advocate for 24-hour access to professional interpreter services, including for American Sign Language, and/or interpreters trained in crisis management for patients and families with limited English proficiency.

Develop standards and systems to establish consultation and acute referral networks within hospitals and communities.

Develop systems for care linkages and follow-up to help patients navigate the complex mental health system, including referral to outpatient and community behavioral health centers.

Leverage technology, including electronic apps and social media, for safety planning to improve follow-up/contact (eg, ED SAFE, Tennessee program for treatment/supplement treatment interventions, for accessioning help; Colorado suicide app for teens 36 – 41   ).

Ensure an appropriate and safe environment for patients with MBH disorders (eg, quiet environment and schedule for children with autism spectrum or developmental disorders, safe shower facilities with no hanging cords for patient presenting with suicidal ideation or attempt).

Provide resources for ED staff to deliver culturally appropriate care with a trauma-informed approach. This should include considerations for addressing systemic racism and implicit bias.

Advocate for community-based behavioral services using a culturally sensitive, patient-centered approach to identify and manage behavioral health concerns before development of an emergency condition.

Develop school-based screening and provide resources for staff to recognize special MBH issues related to children and youth who are victims of bullying, abuse, domestic violence, sexual violence, racism, and trauma. This should also include early identification and referral to appropriate resources, previously identified.

Address behavioral health equity in the community for MBH disorders, including prevention, treatment, and recovery programs for substance use disorders, particularly in vulnerable populations affected by poverty, racism, violence, and food/housing insecurity. 9  

Advocate for adequate pediatric MBH resources in both inpatient and outpatient settings, including the availability of prompt psychiatric consultation and interpreter services for the ED, as well as school and community screening resources.

Establish standards for documentation, communication, and appropriate billing and payment for inpatient and outpatient psychiatric care by mental health specialists consulting on ED patients (including telemedicine consults), as well as for emergency and prolonged ED care for psychiatric borders.

Create interfacility transfer agreements, including simplification of psychiatric bed search for patients requiring further care as inpatient, to help limit ED boarding.

Advocate for referral networks with inclusive mental health coverage, including for those who may be uninsurable (eg, undocumented immigrant children).

Recognize the medical home as a critical component of MBH in a whole-person care approach for the primary care physicians, PAs, and NPs. Advocate for enhancing residency education in pediatrics, medicine-pediatrics, and family medicine related to pediatric MBH conditions. Primary care physicians, PAs, and NPs should be provided with resources to provide psychiatric care as part of the medical home and to receive appropriate payment for these services.

Optimize and expand insurance coverage for MBH coverage to overcome limitations of service to children with MBH conditions. Provider networks should include adequate pediatric-trained mental health specialists to serve their patients. Insurance should cover access to pediatric mental health care and case management programs for those with chronic mental illness, high-risk conditions, developmental disabilities, and substance use disorders.

Advocate for increased funding for the training and compensation of a diverse population of pediatric mental health specialists to help address inadequate access secondary to the shortage of qualified mental health care specialists.

Include MBH topics in the educational curriculum of prehospital personnel, emergency physicians, PAs, NPs, staff, nurses, and trainees, including emergency medicine residents and pediatric emergency medicine fellows to provide patient-centered, trauma-informed, and culturally appropriate care.

Identify current gaps, barriers, and opportunities to improve the current state of MBH care, including supporting programs to increase the diversity of MBH specialists caring for patients in the emergency setting.

Establish models for improving capacity at the systems level for MBH care services in the entire emergency care spectrum, including those awaiting transfer to higher levels of psychiatric care (eg, inpatient psychiatric hospital beds, community-based acute treatment placement).

Because there are trends of increasing numbers of patients with MBH conditions boarding in both the ED 28 , 42   and inpatient units, 43 , 44   provision of MBH care is critical for some level of ongoing care. This model may include initiating/titrating psychiatric medication for medication management, ED environmental modifications, individual and family therapy, and development of coping skills. 44 , 45  

Increase in MBH research funding for EMS for children strategies to screen, identify, and connect to appropriate resources.

Support the research and development of evidence-based guidelines and best practices for ED screening tools, assessment, consultation, acute management, and follow-up care related to children’s mental health crises.

Advance research related to the acute management of pediatric MBH disorders and potential prevention strategies for MBH emergencies (eg, acute psychiatric care models in the ED and inpatient units, psychiatric telehealth consultations for the ED, role of mass media in teen suicidality and depression, and implementation of community mobile crisis teams responding to multiple settings).

Expand research efforts focused on reducing risk factors for youth and examine health inequities related to MBH presentations and management, with the goal of addressing and eliminating these disparities. These risk factors include those unique to certain populations, including but not limited to: historically marginalized and racial and ethnic groups, LGBQT+ youth, immigrants and refugees, children in the welfare system, youth with substance use disorders, intellectual disability, low socioeconomic status, history of exposure to trauma or violence, involvement in the child welfare system, involvement in the juvenile justice system, and limited English proficiency. These research efforts should include the epidemiology of MBH presentations of children and youth to the ED and interventions focused on mental health-related inequities in care and outcomes.

Advance research to better understand the effects of racism and its effects on MBH. This research should include interventional studies to address inequities in mental health care access and outcomes, and care of children and youth of historically disadvantaged racial and ethnic groups.

Develop and validate quality indicators and metrics to improve and standardize ED care of children and youth presenting with MBH concerns. These quality indicators and metrics must also include a health equity lens, examining disparities in care based on race or ethnicity, sexual orientation, gender identity, chronic conditions, socioeconomic status, and limited English proficiency, as well as other factors.

Assess the readiness of EDs in the United States to care for children’s mental health emergencies to help identify gaps, needs, and innovations in care.

Develop models to incorporate MBH evaluation and treatment areas in the ED, where feasible ( Table 1 ). This can include specifically designated spaces. These models have demonstrated improvement in patient and family experience for conducting confidential evaluation and treatment, and have allowed more efficient use of psychiatric consultant time. 45 – 53  

Support development of up-to-date, easily accessible, and searchable online inventories of community mental health referral networks.

Develop national professional standards for children’s mental health consultations.

Develop mental health support networks that minimize reliance on acute crisis management.

Advocate for optimizing and expanding insurance coverage, especially for states that have not expanded Medicaid, to improve mental health care screening and treatment of children and youth.

Mental and behavior health emergencies are increasing in children and youth. EDs have been seriously affected by the increases as the safety net for a system with critical shortcomings. The time has come to address this health care crisis through the following methods: addressing MBH inequities; increasing screening of ED patients for MBH conditions; identifying, treating, and referring children and youth with MBH emergencies; improving access to resources for patients and staff; utilizing standardized treatment protocols; and optimizing the use of telehealth in the treatment of pediatric patients with MBH emergencies. A dedicated multipronged, multidisciplinary approach will be necessary to provide patient-centered, trauma-informed services to improve the care of children and youth with MBH emergencies.

Mohsen Saidinejad, MD, MS, MBA, FAAP, FACEP

Susan Duffy, MD, MPH, FAAP

Dina Wallin, MD

Jennifer A. Hoffmann, MD, FAAP

Madeline Joseph, MD, FAAP, FACEP

Jennifer Schieferle Uhlenbrock, DNP, MBA, RN, TCRN

Kathleen Brown, MD, FAAP

Muhammad Waseem, MD, MS, FAAP, FACEP, CHSE-A

Sally Snow, BSN, RN, CPEN, FAEN

Madeline Andrew, MD

Alice A. Kuo, MD, PhD, MBA, FAAP

Carmen Sulton, MD, FAAP

Thomas Chun, MD, MPH, FAAP

Lois K. Lee, MD, MPH, FAAP, FACEP

Gregory P. Conners, MD, MPH, MBA, FAAP, FACEP, Chairperson

James Callahan, MD, FAAP

Toni Gross, MD, MPH, FAAP

Madeline M. Joseph, MD, FAAP, FACEP

Elizabeth Mack, MD, MS, FAAP

Jennifer Marin, MD, MSc, FAAP

Suzan Mazor, MD, FAAP

Ronald Paul, MD, FAAP

Nathan Timm, MD, FAAP

Mark Cicero, MD, FAAP – National Association of EMS Physicians

Ann Dietrich, MD, FACEP – American College of Emergency Physicians

Andrew Eisenberg, MD, MHA – American Academy of Family Physicians

Mary Fallat, MD, FAAP – AAP Section on Surgery/American College of Surgeons

Ann M. Dietrich, MD, Chairperson

Kiyetta H. Alade, MD

Christopher S. Amato, MD

Zaza Atanelov, MD

Marc Auerbach, MD

Isabel A. Barata, MD, FACEP

Lee S. Benjamin, MD, FACEP

Kathleen T. Berg, MD

Kathleen Brown, MD, FACEP

Cindy Chang, MD

Jessica Chow, MD

Corrie E. Chumpitazi, MD, MS, FACEP

Ilene A. Claudius, MD, FACEP

Joshua Easter, MD

Ashley Foster, MD

Sean M. Fox, MD, FACEP

Marianne Gausche-Hill, MD, FACEP

Michael J. Gerardi, MD, FACEP

Jeffrey M. Goodloe, MD, FACEP (board liaison)

Melanie Heniff, MD, JD, FAAP, FACEP

James (Jim) L. Homme, MD, FACEP

Paul T. Ishimine, MD, FACEP

Susan D. John, MD

Madeline M. Joseph, MD, FACEP

Samuel Hiu-Fung Lam, MD, MPH, RDMS, FACEP

Simone L. Lawson, MD

Moon O. Lee, MD, FACEP

Joyce Li, MD

Sophia D. Lin, MD

Dyllon Ivy Martini, MD

Larry Bruce Mellick, MD, FACEP

Donna Mendez, MD

Emory M. Petrack, MD, FACEP

Lauren Rice, MD

Emily A. Rose, MD, FACEP

Timothy Ruttan, MD, FACEP

Mohsen Saidinejad, MD, MBA, FACEP

Genevieve Santillanes, MD, FACEP

Joelle N. Simpson, MD, MPH, FACEP

Shyam M. Sivasankar, MD

Daniel Slubowski, MD

Annalise Sorrentino, MD, FACEP

Michael J. Stoner, MD, FACEP

Carmen D. Sulton, MD, FACEP

Jonathan H. Valente, MD, FACEP

Samreen Vora, MD, FACEP

Jessica J. Wall, MD

Dina Wallin, MD, FACEP

Theresa A. Walls, MD, MPH

Muhammad Waseem, MD, MS

Dale P. Woolridge, MD, PhD, FACEP

Sam Shahid, MBBS, MPH

Roberta Miller, RN, CPEN, TCRN, Chairperson

Elyssa Wood, PhD, MPH, RN, FAEN

Tasha Lowery, RN, APRN, CEN, CPEN, ENP-C, FNP-C

Julie Cohen, MSN, RN, CPEN, CEN

Rebecca VanStanton, MSN, RN, CEN, CPEN, TCRN

Lisa Hill, DNP, RN, TCRN

Elizabeth Stone, PhD, RN, CPEN, CHSE, FAEN

Domenique Johnson, MSN, RN

We thank Lorah Ludwig, Health Resources and Services Administration, Emergency Medical Services for Children, for her advice and feedback on this paper. We also thank Sam Shahid of American College of Emergency Physicians for all her assistance in the organization of this manuscript.

Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2023-063256 .

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

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Mental Health–Related Emergency Department Visits Among Children Aged <18 Years During the COVID-19 Pandemic — United States, January 1–October 17, 2020

Weekly / November 13, 2020 / 69(45);1675–1680

Rebecca T. Leeb, PhD 1 ; Rebecca H. Bitsko, PhD 1 ; Lakshmi Radhakrishnan, MPH 2 ; Pedro Martinez, MPH 3 ; Rashid Njai, PhD 4 ; Kristin M. Holland, PhD 5 ( View author affiliations )

What is already known about this topic?

Emergency departments (EDs) are often the first point of care for children’s mental health emergencies. U.S. ED visits for persons of all ages declined during the early COVID-19 pandemic (March–April 2020).

What is added by this report?

Beginning in April 2020, the proportion of children’s mental health–related ED visits among all pediatric ED visits increased and remained elevated through October. Compared with 2019, the proportion of mental health–related visits for children aged 5–11 and 12–17 years increased approximately 24%. and 31%, respectively.

What are the implications for public health practice?

Monitoring indicators of children’s mental health, promoting coping and resilience, and expanding access to services to support children’s mental health are critical during the COVID-19 pandemic.

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Published reports suggest that the coronavirus disease 2019 (COVID-19) pandemic has had a negative effect on children’s mental health ( 1 , 2 ). Emergency departments (EDs) are often the first point of care for children experiencing mental health emergencies, particularly when other services are inaccessible or unavailable ( 3 ). During March 29–April 25, 2020, when widespread shelter-in-place orders were in effect, ED visits for persons of all ages declined 42% compared with the same period in 2019; during this time, ED visits for injury and non-COVID-19–related diagnoses decreased, while ED visits for psychosocial factors increased ( 4 ). To assess changes in mental health–related ED visits among U.S. children aged <18 years, data from CDC’s National Syndromic Surveillance Program (NSSP) from January 1 through October 17, 2020, were compared with those collected during the same period in 2019. During weeks 1–11 (January 1–March 15, 2020), the average reported number of children’s mental health–related ED visits overall was higher in 2020 than in 2019, whereas the proportion of children’s mental health–related visits was similar. Beginning in week 12 (March 16) the number of mental health–related ED visits among children decreased 43% concurrent with the widespread implementation of COVID-19 mitigation measures; simultaneously, the proportion of mental health–related ED visits increased sharply beginning in mid-March 2020 (week 12) and continued into October (week 42) with increases of 24% among children aged 5–11 years and 31% among adolescents aged 12–17 years, compared with the same period in 2019. The increased proportion of children’s mental health–related ED visits during March–October 2020 might be artefactually inflated as a consequence of the substantial decrease in overall ED visits during the same period and variation in the number of EDs reporting to NSSP. However, these findings provide initial insight into children’s mental health in the context of the COVID-19 pandemic and highlight the importance of continued monitoring of children’s mental health throughout the pandemic, ensuring access to care during public health crises, and improving healthy coping strategies and resiliency among children and families.

CDC analyzed NSSP ED visit data, which include a subset of hospitals in 47 states representing approximately 73% of U.S. ED visits.* Mental health–related ED visits among children aged <18 years was a composite variable derived from the mental health syndrome query of the NSSP data for conditions likely to result in ED visits during and after disaster events (e.g., stress, anxiety, acute posttraumatic stress disorder, and panic). † Weekly numbers of mental health–related ED visits and proportions of mental health–related ED visits (per 100,000 pediatric ED visits § ) were computed overall, stratified by age group (0–4, 5–11, and 12–17 years) and sex, and compared descriptively with the corresponding weekly numbers and proportions for 2019. Numbers and proportions of visits were compared during calendar weeks 1–11 (January 1–March 14, 2020) and weeks 12–42 (March 15–October 17, 2020) (before and after a distinct decrease in overall ED visits reported beginning in week 12 in 2020) ¶ ( 4 ). Analyses are descriptive and statistical comparisons were not performed.

The number of children’s mental health–related ED visits decreased sharply from mid-March 2020 (week 12, March 15–21) through early April (week 15, April 5–11) and then increased steadily through October 2020. ( Figure 1 ). During the same time, the overall proportion of reported children’s ED visits for mental health–related concerns increased and remained higher through the end of the reporting period in 2020 than that in 2019 (Figure 1). The proportion of mental health–related ED visits among children increased 66%, from 1,094 per 100,000 during April 14–21, 2019 to 1,820 per 100,000 during April 12–18, 2020 (Supplementary Figure 1, https://stacks.cdc.gov/view/cdc/96609 ). Although the average reported number of children’s mental health–related ED visits overall was 25% higher during weeks 1–11 in 2020 (342,740) than during the corresponding period in 2019 (274,736), the proportion of children’s mental health–related visits during the same time was similar (1,162 per 100,000 in 2020 versus 1,044 per 100,000 in 2019). ( Table ). During weeks 12–42, 2020 (mid-March–October) however, average weekly reported numbers of total ED visits by children were 43% lower (149,055), compared with those during 2019 (262,714), whereas the average proportion of children’s mental health–related ED visits was approximately 44% higher in 2020 (1,673 per 100,000) than that in 2019 (1,161 per 100,000).

Adolescents aged 12–17 years accounted for the largest proportion of children’s mental health–related ED visits during 2019 and 2020 ( Figure 2 ). During weeks 12–42, 2020, the proportion of mental health–related visits for children aged 5–11 years and adolescents aged 12–17 years increased approximately 24% and 31%, respectively compared with those in 2019; the proportion of mental health–related visits for children aged 0–4 years remained similar in 2020. (Table.) The highest weekly proportion of mental health–related ED visits occurred during October for children aged 5–11 years (week 42; 1,177 per 100,000) and during April (week 16) for adolescents aged 12–17 years (4,758 per 100,000) (Figure 2).

During 2019 and 2020, the proportion of mental health–related ED visits was higher among females aged <18 years than it was among males (Supplementary Figure 2, https://stacks.cdc.gov/view/cdc/96610 ). Similar patterns of increasing proportions of mental health–related ED visits were observed in 2020 for males and females, with increases beginning mid-March and continuing through October.

Substantial declines in the overall reported numbers of children’s mental health–related ED visits occurred in 2020 during mid-March to early May, coincident with the widespread implementation of community mitigation measures** enacted to prevent COVID-19 transmission (e.g., school closures and restrictions to nonemergent care) and decreases in overall ED visits for the same period ( 4 ). A previous report found the mean weekly number of ED visits for children aged <14 years declined approximately 70% during March 29–April 25, 2020, relative to the corresponding period in 2019 ( 4 ). Further, the mean number of weekly ED visits for persons of all ages decreased significantly for asthma (–10%), otitis media (–65%), and sprain- and strain-related injuries (–39%), and mean weekly ED visits for psychosocial factors increased 69% ( 4 ). This report demonstrates that, whereas the overall number of children’s mental health–related ED visits decreased, the proportion of all ED visits for children’s mental health–related concerns increased, reaching levels substantially higher beginning in late-March to October 2020 than those during the same period during 2019. Describing both the number and the proportion of mental health–related ED visits provides crucial context for these findings and suggests that children’s mental health warranted sufficient concern to visit EDs during a time when nonemergent ED visits were discouraged.

Many children receive mental health services through clinical and community agencies, including schools ( 5 ). The increase in the proportion of ED visits for children’s mental health concerns might reflect increased pandemic-related stress and unintended consequences of mitigation measures, which reduced or modified access to children’s mental health services ( 2 ), and could result in increased reliance on ED services for both routine and crisis treatment ( 3 ). However, the magnitude of the increase should be interpreted carefully because it might also reflect the large decrease in the number and proportion of other types of ED visits (e.g., asthma, otitis media, and musculoskeletal injuries) ( 4 ) and variation in the number of EDs reporting to NSSP.

Adolescents aged 12–17 years accounted for the highest proportion of mental health–related ED visits in both 2019 and 2020, followed by children aged 5–11 years. Many mental disorders commence in childhood, and mental health concerns in these age groups might be exacerbated by stress related to the pandemic and abrupt disruptions to daily life associated with mitigation efforts, including anxiety about illness, social isolation, and interrupted connectedness to school ( 5 ). The majority of EDs lack adequate capacity to treat pediatric mental health concerns ( 6 ), potentially increasing demand on systems already stressed by the COVID-19 pandemic. These findings demonstrate continued need for mental health care for children during the pandemic and highlight the importance of expanding mental health services, such as telemental health and technology-based solutions (e.g., mobile mental health applications) ( 5 , 7 ).

The findings in this report are subject to at least three limitations. First, the proportions presented should be interpreted with caution because of variations affecting the denominators used to calculate proportions. Children’s mental health–related ED visits constitute a small percentage of all pediatric ED visits (1.1% in 2019 and 1.4% in 2020), increasing susceptibility of rates to decreases in ED visits during the pandemic. In addition, NSSP ED participation can vary over time; however, analyzing number of visits and proportion of total ED visits provides context for observed variation. Second, NSSP data are not nationally representative; these findings might not be generalizable beyond those EDs participating in NSSP. Further, usable information on race and ethnicity was not available in the NSSP data. Finally, these data are subject to under- and overestimation. Variation in reporting and coding practices can influence the number and proportion of mental health–related visits observed. ED visits represent unique events, not individual persons, and as such, might reflect multiple visits for one person. The definition of mental health focuses on symptoms and conditions (e.g., stress, anxiety) that might increase after a disaster in the United States and might not reflect all mental health–related ED visits. Still, these data likely underestimate the actual number of mental health–related health care visits because many mental health visits occur outside of EDs.

Children’s mental health during public health emergencies can have both short- and long-term consequences to their overall health and well-being ( 8 ). This report provides timely surveillance data concerning children’s mental health in the context of the COVID-19 pandemic. Ongoing collection of a broad range of children’s mental health data outside the ED is needed to monitor the impact of COVID-19 and the effects of public health emergencies on children’s mental health. Ensuring availability of and access to developmentally appropriate mental health services for children outside the in-person ED setting will be important as communities adjust mitigation strategies ( 3 ). Implementation of technology-based, remote mental health services and prevention activities to enhance healthy coping and resilience in children might effectively support their well-being throughout response and recovery periods ( 5 , 7 ). CDC supports efforts to promote the emotional well-being of children and families and provides developmentally appropriate resources for families to reduce stressors that might contribute to children’s mental health–related ED visits †† ( 9 ).

Acknowledgment

Kathleen Hartnett, CDC.

Corresponding author: Rebecca T. Leeb, [email protected] .

1 Division of Human Development and Disability, National Center on Birth Defects and Developmental Disabilities, CDC; 2 Innovation, Technology, and Analytics Task Force, CDC COVID-19 Response Team; 3 Division of Injury Prevention, National Center for Injury Prevention and Control, CDC; 4 Community Interventions and Critical Populations Task Force, CDC COVID-19 Response Team; 5 Division of Overdose Prevention, National Center for Injury Prevention and Control, CDC.

All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

* The National Syndromic Surveillance Program (NSSP) is a network developed and maintained by CDC, state and local health departments, and academic and private sector health partners to collect electronic health data in real time. NSSP includes ED visit data from a subset of hospitals in 47 states (all but Hawaii, South Dakota, and Wyoming). https://www.cdc.gov/nssp/participation-coverage-map.html ; https://www.cdc.gov/nssp/calculations-for-coverage.html .

† Mental health–related ED visits were defined using the NSSP Syndrome Definition (SD) Subcommittee community-developed syndrome definition for mental health conditions likely to increase in emergency department frequency during and after natural or human-caused disaster events. This syndrome definition attempts to leverage only mental health conditions and presentations that showed increases in visit frequency after select disasters in the United States. There are no disaster-related terms inherent to this query. The query has been added to NSSP BioSense Platform Electronic Surveillance System for the Early Notification of Community-based Epidemics as a Chief Complaint and Discharge Diagnosis category. https://knowledgerepository.syndromicsurveillance.org/disaster-related-mental-health-v1-syndrome-definition-subcommittee .

§ Average proportion of ED visits for children’s mental health = (average number of ED visits for children’s mental health/average total number of ED visits for the same age or sex population [e.g., children aged <18 years]) x 100,000.

¶ To decrease the effect of differential reporting, this analysis was restricted to only include hospitals sending diagnosis codes at patient discharge that are >75% complete and informative, with <20% standard deviation in their values over the previous 2 years.

** https://www.whitehouse.gov/wp-content/uploads/2020/03/03.16.20_coronavirus-guidance_8.5x11_315PM.pdf ; https://www.cdc.gov/coronavirus/2019-ncov/community/community-mitigation.html .

†† https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/parental-resource-kit/ .

• Lee J. Mental health effects of school closures during COVID-19. Lancet Child Adolesc Health 2020;4:421. CrossRef PubMed
• Patrick SW, Henkhaus LE, Zickafoose JS, et al. Well-being of parents and children during the COVID-19 pandemic: a national survey. Pediatrics 2020;146:e2020016824. CrossRef PubMed
• Dolan MA, Fein JA; Committee on Pediatric Emergency Medicine. Pediatric and adolescent mental health emergencies in the emergency medical services system. Pediatrics 2011;127:e1356–66. CrossRef PubMed
• Hartnett KP, Kite-Powell A, DeVies J, et al.; National Syndromic Surveillance Program Community of Practice. Impact of the COVID-19 pandemic on emergency department visits—United States, January 1, 2019–May 30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:699–704. CrossRef PubMed
• Golberstein E, Wen H, Miller BF. Coronavirus disease 2019 (COVID-19) and mental health for children and adolescents. JAMA Pediatr 2020;174:819–20. CrossRef PubMed
• Cree RA, So M, Franks J, et al. Characteristics associated with presence of pediatric mental health care policies in emergency departments. Pediatr Emerg Care 2019. Epub November 13, 2020. CrossRef PubMed
• Gurwitch RH, Salem H, Nelson MM, Comer JS. Leveraging parent-child interaction therapy and telehealth capacities to address the unique needs of young children during the COVID-19 public health crisis. Psychol Trauma 2020;12(S1):S82–4. CrossRef PubMed
• Substance Abuse and Mental Health Services Administration. Disaster technical assistance center supplemental research bulletin: behavioral health conditions in children and youth exposed to natural disasters. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration; 2018. https://www.samhsa.gov/sites/default/files/srb-childrenyouth-8-22-18.pdf
• Stone DM, Holland KM, Bartholow BN, Crosby AE, Jack SPD, Wilkins N. Preventing suicide: a technical package of policies, programs, and practices. Atlanta, GA: US Department of Health and Human Services, CDC; 2017. https://www.cdc.gov/violenceprevention/pdf/suicideTechnicalPackage.pdf

FIGURE 1 . Weekly number of emergency department (ED) mental health–related visits (A) and proportion of (B) children’s mental health–related ED visits per total ED visits* among children aged <18 years — National Syndromic Surveillance Program, United States, January–October 2019 and 2020

* Proportion of mental health–related ED visits = number of ED visits for children’s mental health/total number of pediatric ED visits x 100,000.

* Average proportion of ED visits for children’s mental health = (average number of ED visits for children’s mental health/average total number of ED visits for the same age or sex population [e.g., children aged 18 years]) x 100,000. All numbers have been rounded to the nearest whole number. † Mental health–related ED visits were defined using NSSP’s Syndrome Definition (SD) Subcommittee community-developed syndrome definition for mental health conditions likely to increase in ED frequency during and after natural or human-caused disaster events. This syndrome definition attempts to leverage only mental health conditions and presentations that showed increases in visit frequency after select disasters in the United States. There are no disaster-related terms inherent to this query. The query has been added to NSSP BioSense Platform Electronic Surveillance System for the Early Notification of Community-based Epidemics as a Chief Complaint and Discharge Diagnosis category. https://knowledgerepository.syndromicsurveillance.org/disaster-related-mental-health-v1-syndrome-definition-subcommittee . § Weeks 1–42 in 2019 correspond to December 30, 2018–October 19, 2019; weeks 1–42 in 2020 correspond to December 29, 2019–October 17, 2020. ¶ Weeks 1–11 in 2019 correspond to December 30, 2018–March 16, 2019; weeks 1–11 in 2020 correspond to December 29, 2019–March 14, 2020. ** Weeks 12–42 in 2019 correspond to March 17–October 19, 2019; weeks 12–42 in 2020 correspond to March 15–October 17, 2020.

FIGURE 2 . Weekly proportion of mental health–related emergency department (ED) visits* per total ED visits among children aged <18 years, by age group — National Syndromic Surveillance Program, United States, January–October 2019 and 2020

Suggested citation for this article: Leeb RT, Bitsko RH, Radhakrishnan L, Martinez P, Njai R, Holland KM. Mental Health–Related Emergency Department Visits Among Children Aged <18 Years During the COVID-19 Pandemic — United States, January 1–October 17, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1675–1680. DOI: http://dx.doi.org/10.15585/mmwr.mm6945a3 .

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40 Facts About Elektrostal

Written by Lanette Mayes

Modified & Updated: 02 Mar 2024

Reviewed by Jessica Corbett

Elektrostal is a vibrant city located in the Moscow Oblast region of Russia. With a rich history, stunning architecture, and a thriving community, Elektrostal is a city that has much to offer. Whether you are a history buff, nature enthusiast, or simply curious about different cultures, Elektrostal is sure to captivate you.

This article will provide you with 40 fascinating facts about Elektrostal, giving you a better understanding of why this city is worth exploring. From its origins as an industrial hub to its modern-day charm, we will delve into the various aspects that make Elektrostal a unique and must-visit destination.

So, join us as we uncover the hidden treasures of Elektrostal and discover what makes this city a true gem in the heart of Russia.

Key Takeaways:

• Elektrostal, known as the “Motor City of Russia,” is a vibrant and growing city with a rich industrial history, offering diverse cultural experiences and a strong commitment to environmental sustainability.
• With its convenient location near Moscow, Elektrostal provides a picturesque landscape, vibrant nightlife, and a range of recreational activities, making it an ideal destination for residents and visitors alike.

Known as the “Motor City of Russia.”

Elektrostal, a city located in the Moscow Oblast region of Russia, earned the nickname “Motor City” due to its significant involvement in the automotive industry.

Home to the Elektrostal Metallurgical Plant.

Elektrostal is renowned for its metallurgical plant, which has been producing high-quality steel and alloys since its establishment in 1916.

Boasts a rich industrial heritage.

Elektrostal has a long history of industrial development, contributing to the growth and progress of the region.

Founded in 1916.

The city of Elektrostal was founded in 1916 as a result of the construction of the Elektrostal Metallurgical Plant.

Located approximately 50 kilometers east of Moscow.

Elektrostal is situated in close proximity to the Russian capital, making it easily accessible for both residents and visitors.

Known for its vibrant cultural scene.

Elektrostal is home to several cultural institutions, including museums, theaters, and art galleries that showcase the city’s rich artistic heritage.

A popular destination for nature lovers.

Surrounded by picturesque landscapes and forests, Elektrostal offers ample opportunities for outdoor activities such as hiking, camping, and birdwatching.

Hosts the annual Elektrostal City Day celebrations.

Every year, Elektrostal organizes festive events and activities to celebrate its founding, bringing together residents and visitors in a spirit of unity and joy.

Has a population of approximately 160,000 people.

Elektrostal is home to a diverse and vibrant community of around 160,000 residents, contributing to its dynamic atmosphere.

Boasts excellent education facilities.

The city is known for its well-established educational institutions, providing quality education to students of all ages.

A center for scientific research and innovation.

Elektrostal serves as an important hub for scientific research, particularly in the fields of metallurgy, materials science, and engineering.

Surrounded by picturesque lakes.

The city is blessed with numerous beautiful lakes, offering scenic views and recreational opportunities for locals and visitors alike.

Well-connected transportation system.

Elektrostal benefits from an efficient transportation network, including highways, railways, and public transportation options, ensuring convenient travel within and beyond the city.

Famous for its traditional Russian cuisine.

Food enthusiasts can indulge in authentic Russian dishes at numerous restaurants and cafes scattered throughout Elektrostal.

Home to notable architectural landmarks.

Elektrostal boasts impressive architecture, including the Church of the Transfiguration of the Lord and the Elektrostal Palace of Culture.

Offers a wide range of recreational facilities.

Residents and visitors can enjoy various recreational activities, such as sports complexes, swimming pools, and fitness centers, enhancing the overall quality of life.

Provides a high standard of healthcare.

Elektrostal is equipped with modern medical facilities, ensuring residents have access to quality healthcare services.

Home to the Elektrostal History Museum.

The Elektrostal History Museum showcases the city’s fascinating past through exhibitions and displays.

A hub for sports enthusiasts.

Elektrostal is passionate about sports, with numerous stadiums, arenas, and sports clubs offering opportunities for athletes and spectators.

Celebrates diverse cultural festivals.

Throughout the year, Elektrostal hosts a variety of cultural festivals, celebrating different ethnicities, traditions, and art forms.

Electric power played a significant role in its early development.

Elektrostal owes its name and initial growth to the establishment of electric power stations and the utilization of electricity in the industrial sector.

Boasts a thriving economy.

The city’s strong industrial base, coupled with its strategic location near Moscow, has contributed to Elektrostal’s prosperous economic status.

Houses the Elektrostal Drama Theater.

The Elektrostal Drama Theater is a cultural centerpiece, attracting theater enthusiasts from far and wide.

Popular destination for winter sports.

Elektrostal’s proximity to ski resorts and winter sport facilities makes it a favorite destination for skiing, snowboarding, and other winter activities.

Promotes environmental sustainability.

Elektrostal prioritizes environmental protection and sustainability, implementing initiatives to reduce pollution and preserve natural resources.

Home to renowned educational institutions.

Elektrostal is known for its prestigious schools and universities, offering a wide range of academic programs to students.

Committed to cultural preservation.

The city values its cultural heritage and takes active steps to preserve and promote traditional customs, crafts, and arts.

Hosts an annual International Film Festival.

The Elektrostal International Film Festival attracts filmmakers and cinema enthusiasts from around the world, showcasing a diverse range of films.

Encourages entrepreneurship and innovation.

Elektrostal supports aspiring entrepreneurs and fosters a culture of innovation, providing opportunities for startups and business development.

Offers a range of housing options.

Elektrostal provides diverse housing options, including apartments, houses, and residential complexes, catering to different lifestyles and budgets.

Home to notable sports teams.

Elektrostal is proud of its sports legacy, with several successful sports teams competing at regional and national levels.

Boasts a vibrant nightlife scene.

Residents and visitors can enjoy a lively nightlife in Elektrostal, with numerous bars, clubs, and entertainment venues.

Promotes cultural exchange and international relations.

Elektrostal actively engages in international partnerships, cultural exchanges, and diplomatic collaborations to foster global connections.

Surrounded by beautiful nature reserves.

Nearby nature reserves, such as the Barybino Forest and Luchinskoye Lake, offer opportunities for nature enthusiasts to explore and appreciate the region’s biodiversity.

Commemorates historical events.

The city pays tribute to significant historical events through memorials, monuments, and exhibitions, ensuring the preservation of collective memory.

Promotes sports and youth development.

Elektrostal invests in sports infrastructure and programs to encourage youth participation, health, and physical fitness.

Hosts annual cultural and artistic festivals.

Throughout the year, Elektrostal celebrates its cultural diversity through festivals dedicated to music, dance, art, and theater.

Provides a picturesque landscape for photography enthusiasts.

The city’s scenic beauty, architectural landmarks, and natural surroundings make it a paradise for photographers.

Connects to Moscow via a direct train line.

The convenient train connection between Elektrostal and Moscow makes commuting between the two cities effortless.

A city with a bright future.

Elektrostal continues to grow and develop, aiming to become a model city in terms of infrastructure, sustainability, and quality of life for its residents.

In conclusion, Elektrostal is a fascinating city with a rich history and a vibrant present. From its origins as a center of steel production to its modern-day status as a hub for education and industry, Elektrostal has plenty to offer both residents and visitors. With its beautiful parks, cultural attractions, and proximity to Moscow, there is no shortage of things to see and do in this dynamic city. Whether you’re interested in exploring its historical landmarks, enjoying outdoor activities, or immersing yourself in the local culture, Elektrostal has something for everyone. So, next time you find yourself in the Moscow region, don’t miss the opportunity to discover the hidden gems of Elektrostal.

Q: What is the population of Elektrostal?

A: As of the latest data, the population of Elektrostal is approximately XXXX.

Q: How far is Elektrostal from Moscow?

A: Elektrostal is located approximately XX kilometers away from Moscow.

Q: Are there any famous landmarks in Elektrostal?

A: Yes, Elektrostal is home to several notable landmarks, including XXXX and XXXX.

Q: What industries are prominent in Elektrostal?

A: Elektrostal is known for its steel production industry and is also a center for engineering and manufacturing.

Q: Are there any universities or educational institutions in Elektrostal?

A: Yes, Elektrostal is home to XXXX University and several other educational institutions.

Q: What are some popular outdoor activities in Elektrostal?

A: Elektrostal offers several outdoor activities, such as hiking, cycling, and picnicking in its beautiful parks.

Q: Is Elektrostal well-connected in terms of transportation?

A: Yes, Elektrostal has good transportation links, including trains and buses, making it easily accessible from nearby cities.

Q: Are there any annual events or festivals in Elektrostal?

A: Yes, Elektrostal hosts various events and festivals throughout the year, including XXXX and XXXX.

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Supreme Court wrestles with abortion clash over emergency room treatment for pregnant women

WASHINGTON — The Supreme Court appeared divided Wednesday as it grappled with whether provisions of Idaho's near-total abortion ban unlawfully conflict with a federal law aimed at ensuring certain standards for emergency medical care for patients, including pregnant women.

Some conservative justices, who have a 6-3 majority, appeared skeptical about the Biden administration’s lawsuit arguing that the state ban restricts potentially lifesaving treatment for women suffering complications during pregnancy.

Liberal members of the court appeared to back the administration's position.

The justices are weighing an appeal brought by Idaho officials who are contesting a lawsuit the Biden administration filed over abortion access in emergency situations.

The state abortion law was enacted in 2020, with a provision stating it would go into effect if the Supreme Court overturned Roe v. Wade, the 1973 ruling that found women had a constitutional right to abortion.

The 2020 law, called the Defense of Life Act,  went into effect  in 2022 when the Supreme Court  rolled back  Roe.

The state law says anyone who performs an abortion is subject to criminal penalties, including up to five years in prison. Health care professionals found to have violated the law can lose their professional licenses.

The federal government sued, leading a federal judge in August 2022 to block the state from enforcing provisions concerning medical care that is required under the federal Emergency Medical Treatment and Labor Act, or EMTALA.

The federal law, enacted in 1986, requires that patients receive appropriate emergency room care. The Biden administration argues that care should include abortions in certain situations. The law applies to any hospital that receives federal funding under the Medicare program.

There is an exception to the Idaho law if an abortion is necessary to protect the life of the pregnant woman, although the scope of the exception came under close scrutiny during the oral argument.

Idaho’s lawyer, Joshua Turner, faced tough questioning about whether the exception can also apply to a situation in which a woman has complications that pose a substantial health risk but not imminent death.

Liberal Justice Elena Kagan said federal law says “that you don’t have to wait until the person is on the verge of death.”

“If the woman is going to lose her reproductive organs, that’s enough to trigger this duty on the part of the hospital to stabilize the patient,” she said.

Fellow liberal Justice Sonia Sotomayor asked similar questions, providing several examples of real-life situations in which women have faced emergency situations when doctors had to make calls about whether to authorize abortions, including a situation in which a patient at 16 weeks of pregnancy whose water broke was at risk of sepsis or a hemorrhage after she was refused an abortion in Florida.

"Is that a case in which Idaho the day before would have said it's OK to have an abortion?" Sotomayor asked.

Turner argued that such medical decisions are “subjective” and that a doctor’s judgment in such instances would be based on good faith, not an objective standard.

Justices Amy Coney Barrett and Brett Kavanaugh, both conservatives, indicated they saw Idaho’s law as allowing for treatment similar to what the Biden administration says the federal law requires, suggesting that there may not be any conflict.

At one point Barrett said she was "shocked" at Turner's answers to questions about what kind of treatment was allowed, because "I thought your own expert had said below that these kinds of cases were covered."

Kavanaugh likewise questioned the daylight between the two laws, wondering what the implications are if "Idaho law allows an abortion in each of the emergency circumstances that is identified by the government."

"What does that mean for what we're deciding here?" he asked Turner.

Conservative Justice Samuel Alito seemed most skeptical of the federal government's argument, at one point mentioning language in the federal law referring to treatment for an "unborn child," a term more commonly used by anti-abortion advocates.

"Isn't that an odd phrase to put in a statute that imposes a mandate to perform abortions?" Alito asked Solicitor General Elizabeth Prelogar.

"Have you seen abortion statutes that use the phrase 'unborn child'? Doesn't that tell us something?"

Prelogar responded that the phrase did not displace the requirement that women get the treatment they need in emergency situations.

Conservative justices, including Neil Gorsuch, also questioned whether the federal government even has the power to mandate health standards when they are tied to Medicare funding.

In January, the Supreme Court allowed Idaho to enforce the provisions while also agreeing to hear oral arguments in the case. Other provisions of the ban are already in effect and will not be affected by how the justices rule.

The decision will affect not just Idaho but also other states, including Texas, that have enacted similar abortion bans that abortion-rights advocates say clash with the federal law.

In blocking parts of the state law that conflict with federal law, U.S. District Court Judge B. Lynn Winmill described the state’s actions as putting doctors in a difficult situation.

“The doctor believes her EMTALA obligations require her to offer that abortion right now. But she also knows that all abortions are banned in Idaho. She thus finds herself on the horns of a dilemma. Which law should she violate?” he wrote.

The San Francisco-based 9th U.S. Circuit Court of Appeals briefly put Winmill’s ruling on hold in September, but it subsequently allowed it to go back into effect, prompting the state officials to turn to the Supreme Court.

Prelogar wrote in court papers that EMTALA requires "necessary stabilizing treatment," which in cases involving pregnant women in emergency situations may require abortions.

"And in those limited but critically important circumstances EMTALA requires the hospital to offer that care," she added.

The state argues that it was only after Roe was overturned that the Biden administration said EMTALA could be interpreted to require abortions in some contexts, calling it a "nationwide abortion mandate."

EMTALA "merely prohibits emergency rooms from turning away indigent patients with serious medical conditions," Idaho Attorney General Raúl Labrador wrote in court papers. The law was not intended to override state laws regulating health care, he added.

The Idaho dispute is one of two abortion cases now pending at the Supreme Court, both of which arose in the aftermath of the 2022 decision to overturn Roe v. Wade. In the other case, the court is considering a challenge that could restrict access to mifepristone, the drug most commonly used for medication abortions.

Lawrence Hurley covers the Supreme Court for NBC News.

Health insurance giant Kaiser will notify millions of a data breach after sharing patients’ data with advertisers

U.S. health conglomerate Kaiser is notifying millions of current and former members of a data breach after confirming it shared patients’ information with third-party advertisers, including Google, Microsoft and X (formerly Twitter).

In a statement shared with TechCrunch, Kaiser said that it conducted an investigation that found “ certain online technologies, previously installed on its websites and mobile applications, may have transmitted personal information to third-party vendors.”

Kaiser said that the data shared with advertisers includes member names and IP addresses, as well as information that could indicate if members were signed into a Kaiser Permanente account or service and how members “interacted with and navigated through the website and mobile applications, and search terms used in the health encyclopedia.”

Kaiser said it subsequently removed the tracking code from its websites and mobile apps.

Kaiser is the latest healthcare organization to confirm it shared patients’ personal information with third-party advertisers by way of online tracking code , often embedded in web pages and mobile apps and designed to collect information about users’ online activity for analytics. Over the past year, telehealth startups Cerebral , Monument and Tempest have pulled tracking code from their apps that shared patients’ personal and health information with advertisers.

Kaiser spokesperson Diana Yee said that the organization would begin notifying 13.4 million affected current and former members and patients who accessed its websites and mobile apps. The notifications will start in May in all markets where Kaiser Permanente operates, the spokesperson said.

The health giant also filed a legally required notice with the U.S. government on April 12 but made public on Thursday confirming that 13.4 million residents had information exposed.

U.S. organizations covered under the health privacy law known as HIPAA are required to notify the U.S. Department of Health and Human Services of data breaches involving protected health information, such as medical data and patient records. Kaiser also notified California’s attorney general of the data breach, but did not provide any further details.

The Kaiser Foundation Health Plan is the parent organization of several entities that make up Kaiser Permanente, one of the largest healthcare organizations in the United States. The Kaiser Foundation Health Plan provides health insurance plans to employers and reported 12.5 million members as of the end of 2023.

The breach at Kaiser is listed on the Department of Health and Human Services’ website as the largest confirmed health-related data breach of 2024 so far.

To contact this reporter, get in touch on Signal and WhatsApp at +1 646-755-8849, or by email . You can also send files and documents via  SecureDrop .