Nelson D S, Hoagland J R, Kunkel N C
Division of Pediatric Emergency Medicine, Primary Children's Medical Center, Salt Lake City, Utah 84113, USA.
Pediatr Emerg Care. 2000 Apr;16(2):80-4. doi: 10.1097/00006565-200004000-00003.
Many agents suitable for pediatric outpatient sedation have been identified and compared, but less data have appeared on the effect of sedation use on Emergency Department (ED) length of stay (LOS) or visit costs. We sought to discover the relationship between one commonly used method of sedation, orally administered midazolam, and ED LOS and visit costs. Parents were then surveyed to determine their attitudes toward sedation given knowledge of these costs.
All ED patients under 10 years of age seen in a pediatric ED during April and May of 1996 for repair of lacerations <2.5 cm in length were identified via retrospective chart review. Children were excluded if they had other significant injuries, received sedatives other than oral midazolam, or were repaired by non-ED physicians. Preliminary cost and LOS data from this review was used to create a parental survey measuring attitudes toward the costs of an unnamed form of sedation (not mentioning oral midazolam). A convenience sample of parents in an ED waiting room were asked if they would want sedation administered to a child needing sutures if this increased the visit cost by $100 and/or increased LOS by 30 minutes. Parents were then asked to re-answer these questions assuming that the sedation medication was effective only 50% of the time.
Of 120 patients meeting entry criteria, 57 (48%) received oral midazolam. Children sedated with this agent were significantly younger (3.6 vs. 4.6 years, P = 0.015), had more layered repairs (30% vs. 14%, P = 0.047), and more facial lacerations (84% vs. 63%, P = 0.01) when compared with nonsedated patients. Mean LOS for patients with simple lacerations receiving oral midazolam increased by 17.1 minutes (P = 0.03) compared with nonsedated children; for layered repairs, the mean increase was 30.9 minutes (P<0.05). The use of oral midazolam did not effect physician charges, but did significantly increase mean combined nurse/hospital charges and total charges by 73 to 87 dollars, depending on laceration type (P<0.001 all cases). Of 81 parents surveyed, 81% said that they would be willing to wait 30 extra minutes for sedation to be used; this figure fell to 73% if sedation was effective 50% of the time. Seventy-five percent of parents were willing to pay $100 extra for sedation; 67% if sedation was effective only half the time. Willingness to endure a longer LOS or pay increased charges was not associated with parental sex or insurance status.
The use of oral midazolam significantly increases ED visit LOS and cost. This information is important to review with parents when discussing sedation options. Up to one third of parents surveyed would not want to wait extra time or pay extra money for sedation to be administered, especially if the efficacy of the chosen method was not assured.
已确定并比较了许多适用于儿科门诊镇静的药物，但关于镇静药物使用对急诊科（ED）留观时间（LOS）或就诊费用影响的数据较少。我们试图探究一种常用的镇静方法，即口服咪达唑仑，与ED留观时间和就诊费用之间的关系。然后对家长进行调查，以确定他们在了解这些费用后对镇静的态度。
通过回顾性病历审查，确定了1996年4月和5月在一家儿科急诊科就诊的所有10岁以下因长度小于2.5 cm的裂伤进行缝合的ED患者。如果儿童有其他严重损伤、接受了除口服咪达唑仑以外的镇静剂或由非ED医生进行缝合，则将其排除。此次审查的初步费用和留观时间数据用于创建一份家长调查问卷，以衡量家长对一种未提及名称的镇静方式（未提及口服咪达唑仑）费用的态度。在ED候诊室对方便抽样的家长进行询问，如果给需要缝合的儿童使用镇静剂会使就诊费用增加100美元和/或留观时间增加30分钟，他们是否希望给孩子使用镇静剂。然后要求家长在假设镇静药物仅50%有效的情况下重新回答这些问题。
在120名符合入选标准的患者中，57名（48%）接受了口服咪达唑仑。与未接受镇静的患者相比，使用该药物镇静的儿童明显更年幼（3.6岁对4.6岁，P = 0.015），有更多分层缝合（30%对14%，P = 0.047），以及更多面部裂伤（84%对63%，P = 0.01）。与未接受镇静的儿童相比，接受口服咪达唑仑的单纯裂伤患者的平均留观时间增加了17.1分钟（P = 0.03）；对于分层缝合，平均增加30.9分钟（P<0.05）。口服咪达唑仑的使用对医生收费没有影响，但根据裂伤类型，确实使护士/医院平均联合收费和总收费显著增加了73至87美元（所有情况P<0.001）。在接受调查的81名家长中，81%表示他们愿意多等30分钟使用镇静剂；如果镇静剂仅50%有效，这一数字降至73%。75%的家长愿意为镇静多支付100美元；如果镇静剂仅一半时间有效，这一比例为67%。忍受更长留观时间或支付更高费用的意愿与家长性别或保险状况无关。
口服咪达唑仑的使用显著增加了ED就诊的留观时间和费用。在讨论镇静选择时，将此信息告知家长很重要。多达三分之一接受调查的家长不想为使用镇静剂而多等时间或多花钱，尤其是如果所选方法的疗效不确定。
