Patient characteristics associated with hospital admission or antiarrhythmic medication changes after emergency department evaluation of supraventricular tachycardia

Patient characteristics associated with hospital admission or antiarrhythmic medication changes after emergency department evaluation of supraventricular tachycardia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Patient characteristics associated with hospital admission or antiarrhythmic medication changes after emergency department evaluation of supraventricular tachycardia Kyle A Schmucker, Caroline S Morris, Robert T Tisherman, Mioara Manole, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3060936/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 10 Aug, 2023 Read the published version in Pediatric Cardiology → Version 1 posted 8 You are reading this latest preprint version Abstract Background Supraventricular tachycardia (SVT) is a relatively frequent diagnosis in the pediatric emergency department (ED). However, there are no consensus guidelines for ED disposition, and there are limited data on ED outcomes. Better understanding of those who are admitted or have antiarrhythmic medication changes may avoid potentially unnecessary transfers or admissions. Our objective was to identify patient factors associated with discharge from the emergency department without medication initiation or modification after management of SVT in the pediatric ED. Design/Methods A retrospective review of children aged 0-18 years seen in the emergency department for SVT was conducted using electronic medical record data over a ten-year period at a single academic tertiary children’s hospital. Patients with congenital cardiac disease or prior cardiac surgeries were excluded. Multivariable logistic regression analysis was used to determine association between patient factors of interest and the primary outcome of admission and secondary outcome of change to antiarrhythmic medications. Results We analyzed 197 patients encounters. The mean age was 7 years. Of these 104 (52.8%) were admitted to the hospital or discharged with antiarrhythmic medication changes. This primary outcome was associated with younger age (aOR 0.77, 95% CI 0.67-0.86), history of pre-excitation (aOR 5.82, 95% CI 2.01-18.8), intercurrent illness (aOR 3.75, 95% CI 1.27-12.1), number of adenosine doses prior to arrival (aOR 5.45, 95% CI 1.55-22.3), and in-person cardiology consultation (aOR 6.42, 95% CI 2.43-19.4). Conclusions Nearly half of children treated in a pediatric ED for SVT are discharged without changes in medications. We identified patient factors associated with hospital admission or antiarrhythmic medication changes. These factors represent high value care and can be assessed when considering transfer from a referring facility. Risk stratification using these patient characteristics may reduce potentially avoidable transfers and admissions. supraventricular tachycardia emergency department pediatric prehospital transfer Background Supraventricular tachycardia (SVT) is a frequent diagnosis in the pediatric emergency department (ED), affecting between 1 in 250 and 1 in 1,000 children [1]. The management of pediatric SVT varies widely in EDs, [2] especially with regards to patient disposition after resolution of SVT. There are no consensus guidelines on which patients require a higher level of care, admission for further monitoring and management, or are safe for discharge after medication initiation or adjustment. Prior research demonstrates a discharge rate of 60% for pediatric patients treated for SVT with adenosine in pediatric EDs [3]. Similar data are not available for patients treated in general EDs. Avoidance of unnecessary transfers has become a point of interest in emergency medicine and prehospital research [4]. Potentially avoidable transfers represent a significant burden to limited hospital-based care, emergency medical services (EMS), patients, and families [5]. Previous studies have investigated ED transfers from urgent care centers, to define essential versus non-essential transfers based on a variety of patient care characteristics and diagnostic studies performed at the receiving center [6]. To our knowledge, there are no studies investigating the demographics or outcomes of pediatric patients presenting with SVT who do not require hospitalization or direct management by cardiology. After the acute management of pediatric SVT, centers with limited access to pediatric resources are often challenged with determining safe disposition plans. The objective of this study is to identify patient factors associated with discharge from the emergency department without medication initiation or modification after management of SVT in the pediatric ED. Methods We conducted a retrospective cross-sectional analysis of pediatric subjects ages 0–18 years old evaluated at a tertiary children’s hospital SVT from 2013–2020. Our facility serves as the only pediatric hospital in the region. The study was approved by the institutional review board of the University of Pittsburgh Children presenting to the ED and patients transferred from another hospital for a tachycardia-related complaint were included. We identified subjects with SVT by query of an electronic medical records for patients treated from January 2003-January 2020 with International Classification of Diseases (ICD) 9 or ICD 10 codes 427.0 (SVT). To capture patients with SVT who may have received incorrect ICD codes, we also searched 427.89 (Other Arrhythmia), 427.1 (ventricular tachycardia), 427.41 (ventricular fibrillation), and 427.9 (cardiac arrhythmia) and included those confirmed to have a final diagnosis of SVT for this encounter upon hospitalization or follow up. We also identified emergency department patients who received adenosine in the emergency department to identify additional subjects who did not receive an ICD code for SVT. Subjects with structural heart disease or previous cardiac surgery were excluded. Electronic medical records for each queried patient were manually reviewed by two of the study authors (KS, CM). Those not meeting inclusion criteria were excluded after chart review. Investigators reviewed available prehospital records, ED notes, consult notes, hospital and ICU notes. All cardiology and ED documentation available until the date of data extraction in 2021 were reviewed for follow up information to determine recurrence of SVT within 48 hours. Patient factors including age, sex, medical comorbidities, presence of intercurrent illness, medications and interventions performed, transfer status from an outside facility, and modality of transfer were extracted from the medical record. Subjects were defined as receiving “additional care” if they were 1) admitted for inpatient management or 2) had a change in home antiarrhythmic medication or were started on a new antiarrhythmic medication. The retrospective review of all patients meeting inclusion criteria was performed at a visit-level (i.e. multiple visits for the same patient were analyzed separately), allowing inclusion of patients who were seen in the ED on more than one occasion for SVT. Descriptive statistics are all presented as mean ± standard deviation unless otherwise noted in cases where non-parametric distributions were present. Bivariate logistic regression analysis was performed between all variables in Table 1 (age, home controller medication, medical comorbidities, history of SVT, history of pre-excitation, intercurrent illness, transfer from outside facility, number of adenosine doses prior to arrival, total number of adenosine doses, electrical cardioversion, duration of SVT at the time of evaluation, seen in person by cardiology) and no collinearity was established. Multivariable logistic regression analysis was performed between the primary outcome of meaningful additional care (combined admission to hospital and/or change in cardiac medications) and all patient demographic variables. Significance was set apriori at p ≤ 0.05 for all statistical comparisons (Prism 9.3.0, GraphPad, San Diego, CA). Results Demographics and patient characteristics One-hundred and ninety-seven encounters met inclusion criteria with mean age of 7.3 ± 6.0 years (Table 1 ). Of those included, 53.7% were female (n = 87), 46.9% had non-cardiac medical comorbidities (n = 92), 51.5% had a history of SVT previously (n = 101), 27.5% were previously on a home-controller medication for SVT (n = 54), and 14.8% had a history of pre-excitation (n = 29). On initial evaluation at the study site, 55 subjects (27.9%) were reported to have an intercurrent illness at the time of presentation. The duration of SVT was less than one hour in 47 subjects (23.8%), between one and four hours in 31 (15.7%), between 4 and twelve hours in 11 (5.6%) and greater than 12 hours in one subject (0.5%). The remaining 90 subjects (45.7%) had unknown duration of symptoms. Table 1 Characteristics of patients meeting inclusion criteria. SVT – supraventricular tachycardia, IQR – interquartile range Overall (n = 197) Admitted to Hospital (n = 79) Change in Cardiac Medication (n = 88) p Age (years), median [IQR] 7.0 [0.8–13.0] 0.8 [0.1–9.0] 0.9 [0.1–5.3] < 0.001 Duration of SVT, n (%) 0.19 Unknown 107 (54.3) 52 (65.8) 63 (71.6) Under 1 hour 47 (23.9) 14 (17.7) 13 (14.8) 1–4 hours 31 (15.7) 8 (10.1) 7 (8.0) 4–12 hours 11 (5.6) 4 (5.1) 4 (4.5) Greater than 12 hours 1 (0.5) 1 (1.3) 1 (1.1) Medical Comorbidities, n (%) 92 (46.7) 35 (44.3) 40 (45.5) 0.93 History of preexcitation, n (%) 29 (14.3) 18 (22.8) 24 (27.3) 0.03 History of SVT, n (%) 101 (49.8) 33 (41.8) 49 (55.7) 0.18 On controller medication, n (%) 54 (27.6) 24 (30.4) 35 (39.8) 0.14 Intercurrent Illness, n (%) 55 (27.4) 34 (43.0) 34 (38.6) 0.03 Transfer from another facility, n (%) 59 (30.6) 26 (32.9) 27 (30.7) 0.96 Number of adenosine doses prior to arrival, median [IQR] 0 [0–1] 0 [0–1] 0 [0–1] 0.86 Total number of adenosine doses, median [IQR] 1 [0–2] 1 [0–2] 1 [0–2] 0.16 Cardioversion, n (%) 6 (3.1) 5 (6.3) 5 (5.7) 0.38 Seen in person by cardiology, n (%) 105 (54.1) 50 (63.3) 56 (63.6) 0.15 Interventions performed At the time of presentation to the study site, 59 of 197 subjects (29.9%) presented as transfers from another facility. The majority (n = 139, 69.0%) did not receive adenosine prior to arrival at the study site after transfer via EMS or outside referral. In total, 87 subjects (44.1%) did not receive any doses of adenosine from prehospital, outside facility, or the study site. Of those who were chemically cardioverted with adenosine, 57 (28.9%) received one dose, 33 (16.8%) received two doses, 18 (9.1%) received three doses, and two (1.0%) received four doses. Six subjects (3.0%) received electrical cardioversion. Six patients (4.3%) arrived via transfer in active SVT. Cardiology was consulted for in-person evaluation in the pediatric ED in 105 cases (53.3%). Baseline characteristics of those evaluated by cardiology vs not evaluated were compared (Table 2 ). The median age of those evaluated by cardiology was 5 years compared to 10 years in those not evaluated in person (p = 0.0047). A smaller percentage (45%) of those evaluated by cardiology had a history of SVT compared to those not evaluated (54%) (p = 0.013). One-hundred eighteen subjects (59.9%) were discharged to home from the ED and 79 (40.1%) were admitted to the hospital. A total of 88 children (44.7%) had changes made to their cardiac medication regimen, either in the ED or after admission. The combined outcome of admission to the hospital or change in cardiac medications occurred in 104 visits (52.8%). Of the 93 subjects discharged without medication changes, two (2.0%) returned to the ED within 48 hours with recurrence of SVT. Table 2 Characteristics of patients seen by cardiology in person versus not seen by cardiology in person Not evaluated by cardiology (n = 89) Evaluated by cardiology (n = 105) p Age (years), median [IQR] 10.0 [1.5–14.0] 5.0 [0.21–11.5] 0.0047 Duration of SVT, n (%) 0.63 Unknown 45 (50.6) 60 (57.1) Under 1 hour 25 (28.1) 21 (20.0) 1–4 hours 14 (15.7) 17 (16.2) 4–12 hours 5 (5.6) 6 (5.7) Greater than 12 hours 0 (0.0) 1 (1.0) Medical Comorbidities, n (%) 41 (46.0) 49 (46.7) 0.94 History of preexcitation, n (%) 11 (12.4) 18 (17.1) 0.35 History of SVT, n (%) 54 (60.7) 45 (42.9) 0.013 On controller medication, n (%) 29 (33.0) 24 (22.9) 0.11 Intercurrent Illness, n (%) 22 (24.7) 32 (30.5) 0.42 Transfer from another facility, n (%) 20 (24.1) 37 (36.6) 0.078 Number of adenosine doses prior to arrival, median [IQR] 0 [0–1] 0 [0–1] 0.83 Total number of adenosine doses, median [IQR] 1 [0–1] 1 [0–2] 0.065 Cardioversion, n (%) 2 (2.3) 4 (3.9) 0.69 Admitted to hospital, n (%) 27 (30.3) 50 (47.6) 0.018 Change in home controller medication, n (%) 32 (36.8) 56 (53.3) 0.029 Of subjects transferred from a referring facility (n = 59), 26 (44.1%) were admitted to the hospital. Five children (8.5%) underwent changes to their cardiac medications and were subsequently discharged home from the pediatric ED. The remaining patients (n = 28, 47.5%) who presented as transfers were discharged to home with no changes in cardiac medications. Of these, (n = 19, 67.9%) were evaluated by cardiology. Multivariable Logistic Regression A multivariable logistic regression model was created with the primary outcome of combined admission to the hospital and/or change in cardiac medication (Table 3 ). Patient factors significantly associated with the primary outcome included age (aOR 0.77, 95% CI 0.67–0.86), history of pre-excitation (aOR 5.82, 95% CI 2.01–18.8), intercurrent illness (aOR 3.75, 95% CI 1.27–12.1), number of adenosine doses prior to arrival (aOR 5.45, 95% CI 1.55–22.3), and in- person cardiology consultation (aOR 6.42, 95% CI 2.43–19.4). The overall area under the curve of the predictive model was 0.92 (p < 0.001) with a negative predictive value of 85.1% and a positive predictive value of 81%. Table 3 Results of multivariable regression analysis with combined endpoint of admission to hospital or change in controller medication. Patient Factor (n = 197) aOR 95% CI P-value Age 0.77 0.67–0.86 < 0.001 Duration of SVT 0.86 0.48–1.53 0.60 Medical Comorbidities 1.41 0.35–5.87 0.63 History of preexcitation 5.82 2.01–18.83 0.0016 History of SVT 0.75 0.18–3.18 0.69 On controller medication at home 2.88 0.66–13.53 0.16 Intercurrent Illness 3.75 1.27–12.07 0.020 Transfer from another facility 0.47 0.16–1.24 0.14 Number of adenosine doses prior to arrival 5.45 1.55–22.30 0.013 Total number of adenosine dose 1.06 0.58–1.98 0.86 Electrical Cardioversion 0.67 0.10–3.09 0.63 Seen in person by cardiology 6.42 2.43–19.37 < 0.001 Discussion The results of the present study indicate that a majority (59%) of patients were discharged to home without a change to their cardiac medications after pediatric ED management of SVT. Previous research has demonstrated wide variation in admissions ranging from 19–85% at comparable children’s EDs nationwide [2]. To our knowledge, this is the first study evaluating patients undergoing changes to cardiac medications as a primary outcome. Multiple factors were found to be significantly associated with admission or change in cardiac medication. Younger age was associated with receiving additional care in this study. Younger patients (< 1-year-old) have a higher risk of SVT, and previous literature has shown that younger patients are less responsive to adenosine [7]. Additionally, limited history in younger children make it challenging to determine the duration of SVT and gauge their risk of heart failure [8]. A history of pre-excitation was found to be significantly associated with need for admission or change in cardiac medication in this study. Underlying conditions, such as Wolff-Parkinson-White Syndrome, have been estimated to carry a lifetime mortality rate of 3–4% [9]. Clinicians likely view instances of tachyarrhythmias in these patients as higher risk and therefore warrant additional monitoring. Patients with Wolff-Parkinson-White Syndrome also have a higher risk of recurrent SVT, perhaps influencing cardiologists to more closely adjust their medications if discharged. The presence of an intercurrent illness was also associated with admission to the hospital or change in cardiac medication. Acute illness is a known trigger of SVT in those prone to the condition. It is unclear from the data if these patients are admitted due to the acute illness or because SVT is viewed as a disease severity marker. Patients receiving multiple doses of adenosine, representing refractory SVT, are likely to need prolonged critical care treatment time. We found that patients receiving additional doses of adenosine were more likely to be admitted to the hospital, likely due to concern for recurrence from the managing medical team. Further research is needed to determine if refractory SVT is associated with recurrence. In person evaluation by a cardiologist was also associated with admission or discharge with medication changes. Patients evaluated by cardiology were younger, in part explaining this difference. Interestingly, cardiology evaluated in person a higher percentage of patients without a history of SVT. Perhaps this is again explained by younger age where evaluation of infants with first time SVT will not carry a prior diagnosis. Additionally, patients who were evaluated by cardiology likely represent more complex cases and are more likely to be admitted to the hospital or have medication changes. Interestingly, factors such as time of day of arrival, distance traveled, transfer status, and air ambulance transfer were not associated with increased care. It may be interpreted that momentum at the time of transfer does not dictate care received after arrival. However, it does underscore the importance of critically evaluating these transfers as patients were often discharged after consultation with cardiology. This presents a unique opportunity for transfer centers to improve care by offering cardiology consultation to referring institutions. Limitations This is a single center study. As previously discussed, management of SVT is variable across sites and throughout the country, therefore the local practices reported in this study may not apply to every region. An additional limitation is the ease of pediatric cardiology consultation, which may increase the rate of which this consultation is obtained at the tertiary care center studied. Further, this study describes associations with receiving additional care, but we cannot determine how this care affects patient outcomes. A prospective quality improvement project looking at telemedicine and virtual consultation instead of transfer to a tertiary center for patients with SVT is currently underway. Conclusions Nearly half of children treated in a pediatric ED for SVT are discharged without changes in medications. Younger age, receiving multiple doses of adenosine, history of preexcitation, intercurrent illness, and in-person cardiology consultation are associated with hospital admission or antiarrhythmic medication changes. These factors represent high value care and can be assessed when considering transfer from a referring facility. Risk stratification using these patient characteristics may reduce potentially avoidable transfers and admissions. Declarations All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Kyle Schmucker, Caroline Morris, Jennifer Dunnick, and Robert Tisherman. The first draft of the manuscript was written by Kyle Schmucker and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Compliance with Ethical Standards None of the authors have competing interests or funding to disclose. This retrospective chart review study involving human participants was in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The Human Investigation Committee (IRB) of The University of Pittsburgh approved this study. References Reyes G, Stanton R, Galvis AG. Adenosine in the treatment of paroxysmal supraventricular tachycardia in children. Ann Emerg Med . 1992;21(12):1499-1501. doi:10.1016/s0196-0644(05)80069-1 Przybylski R, Michelson KA, Neuman MI, Porter JJ, Alexander ME, Lyons TW. Care of Children with Supraventricular Tachycardia in the Emergency Department. Pediatr Cardiol . 2021;42(3):569-577. doi:10.1007/s00246-020-02515-8 Díaz-Parra S, Sánchez-Yañez P, Zabala-Argüelles I, et al. Use of adenosine in the treatment of supraventricular tachycardia in a pediatric emergency department. Pediatr Emerg Care . 2014;30(6):388-393. doi:10.1097/PEC.0000000000000144 Varma S, Schinasi DA, Ponczek J, et al. A Retrospective Study of Children Transferred from General Emergency Departments to a Pediatric Emergency Department: Which Transfers Are Potentially Amenable to Telemedicine? J Pediatr . 2021;230:126-132.e1. doi:10.1016/j.jpeds.2020.10.070 Mohr NM, Harland KK, Shane DM, Miller SL, Torner JC. Potentially Avoidable Pediatric Interfacility Transfer Is a Costly Burden for Rural Families: A Cohort Study. Acad Emerg Med . 2016;23(8):885-894. doi:10.1111/acem.12972 Olympia RP, Wilkinson R, Dunnick J, Dougherty BJ, Zauner D. Pediatric Referrals to an Emergency Department From Urgent Care Centers. Pediatr Emerg Care . 2018;34(12):872-877. doi:10.1097/PEC.0000000000000955 Lewis J, Arora G, Tudorascu DL, Hickey RW, Saladino RA, Manole MD. Acute Management of Refractory and Unstable Pediatric Supraventricular Tachycardia. J Pediatr . 2017;181:177-182.e2. doi:10.1016/j.jpeds.2016.10.051 Sabaté Rotés A, Figueras Coll M, Gran Ipiña F, et al. Supraventricular tachycardia in children from the perspective of a specialised between-hospital transport team. An Pediatr . 2020;93(4):236-241. doi:10.1016/j.anpede.2019.12.012 Munger TM, Packer DL, Hammill SC, et al. A population study of the natural history of Wolff-Parkinson-White syndrome in Olmsted County, Minnesota, 1953-1989. Circulation . 1993;87(3):866-873. doi:10.1161/01.cir.87.3.866 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 10 Aug, 2023 Read the published version in Pediatric Cardiology → Version 1 posted Editorial decision: Major revision 06 Jul, 2023 Reviews received at journal 15 Jun, 2023 Reviewers agreed at journal 15 Jun, 2023 Reviewers agreed at journal 15 Jun, 2023 Reviewers invited by journal 14 Jun, 2023 Editor assigned by journal 14 Jun, 2023 Submission checks completed at journal 14 Jun, 2023 First submitted to journal 14 Jun, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3060936","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":209847189,"identity":"1f5a1e1f-811f-4d7b-850f-8df742604d3a","order_by":0,"name":"Kyle A Schmucker","email":"data:image/png;base64,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","orcid":"","institution":"University of Texas Southwestern Medical Center","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Kyle","middleName":"A","lastName":"Schmucker","suffix":""},{"id":209847191,"identity":"17edd5c0-2a45-4526-ad4b-11e42360290b","order_by":1,"name":"Caroline S Morris","email":"","orcid":"","institution":"UPMC Children’s Hospital of Pittsburgh","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Caroline","middleName":"S","lastName":"Morris","suffix":""},{"id":209847192,"identity":"cb572b54-455a-4976-a4e0-3effb2ecf09a","order_by":2,"name":"Robert T Tisherman","email":"","orcid":"","institution":"UPMC Department of Orthopedics","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Robert","middleName":"T","lastName":"Tisherman","suffix":""},{"id":209847193,"identity":"fab6b809-b4b0-4a48-bc22-268f3a676fd8","order_by":3,"name":"Mioara Manole","email":"","orcid":"","institution":"UPMC Children’s Hospital of Pittsburgh","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mioara","middleName":"","lastName":"Manole","suffix":""},{"id":209847194,"identity":"55d278c6-3fca-437a-a2fc-8e01e4d0746f","order_by":4,"name":"Guarav Arora","email":"","orcid":"","institution":"UPMC Children’s Hospital of Pittsburgh","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Guarav","middleName":"","lastName":"Arora","suffix":""},{"id":209847195,"identity":"9676e4cd-1772-4f8b-a216-ace63ebd0508","order_by":5,"name":"Jennifer Dunnick","email":"","orcid":"","institution":"UPMC Children’s Hospital of Pittsburgh","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jennifer","middleName":"","lastName":"Dunnick","suffix":""}],"badges":[],"createdAt":"2023-06-14 04:59:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3060936/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3060936/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00246-023-03257-z","type":"published","date":"2023-08-10T21:57:36+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":44735332,"identity":"2cd5d341-2357-414d-9346-a53170c6dd21","added_by":"auto","created_at":"2023-10-16 22:24:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":272008,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3060936/v1/0b877684-1298-4efb-9ae0-19f3808154a2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Patient characteristics associated with hospital admission or antiarrhythmic medication changes after emergency department evaluation of supraventricular tachycardia","fulltext":[{"header":"Background","content":"\u003cp\u003eSupraventricular tachycardia (SVT) is a frequent diagnosis in the pediatric emergency department (ED), affecting between 1 in 250 and 1 in 1,000 children [1]. The management of pediatric SVT varies widely in EDs, [2] especially with regards to patient disposition after resolution of SVT. There are no consensus guidelines on which patients require a higher level of care, admission for further monitoring and management, or are safe for discharge after medication initiation or adjustment. Prior research demonstrates a discharge rate of 60% for pediatric patients treated for SVT with adenosine in pediatric EDs [3]. Similar data are not available for patients treated in general EDs.\u003c/p\u003e \u003cp\u003eAvoidance of unnecessary transfers has become a point of interest in emergency medicine and prehospital research [4]. Potentially avoidable transfers represent a significant burden to limited hospital-based care, emergency medical services (EMS), patients, and families [5]. Previous studies have investigated ED transfers from urgent care centers, to define essential versus non-essential transfers based on a variety of patient care characteristics and diagnostic studies performed at the receiving center [6]. To our knowledge, there are no studies investigating the demographics or outcomes of pediatric patients presenting with SVT who do not require hospitalization or direct management by cardiology. After the acute management of pediatric SVT, centers with limited access to pediatric resources are often challenged with determining safe disposition plans.\u003c/p\u003e \u003cp\u003eThe objective of this study is to identify patient factors associated with discharge from the emergency department without medication initiation or modification after management of SVT in the pediatric ED.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe conducted a retrospective cross-sectional analysis of pediatric subjects ages 0\u0026ndash;18 years old evaluated at a tertiary children\u0026rsquo;s hospital SVT from 2013\u0026ndash;2020. Our facility serves as the only pediatric hospital in the region. The study was approved by the institutional review board of the University of Pittsburgh\u003c/p\u003e \u003cp\u003eChildren presenting to the ED and patients transferred from another hospital for a tachycardia-related complaint were included. We identified subjects with SVT by query of an electronic medical records for patients treated from January 2003-January 2020 with \u003cem\u003eInternational Classification of Diseases\u003c/em\u003e (ICD) 9 or ICD 10 codes 427.0 (SVT). To capture patients with SVT who may have received incorrect ICD codes, we also searched 427.89 (Other Arrhythmia), 427.1 (ventricular tachycardia), 427.41 (ventricular fibrillation), and 427.9 (cardiac arrhythmia) and included those confirmed to have a final diagnosis of SVT for this encounter upon hospitalization or follow up. We also identified emergency department patients who received adenosine in the emergency department to identify additional subjects who did not receive an ICD code for SVT. Subjects with structural heart disease or previous cardiac surgery were excluded.\u003c/p\u003e \u003cp\u003eElectronic medical records for each queried patient were manually reviewed by two of the study authors (KS, CM). Those not meeting inclusion criteria were excluded after chart review. Investigators reviewed available prehospital records, ED notes, consult notes, hospital and ICU notes. All cardiology and ED documentation available until the date of data extraction in 2021 were reviewed for follow up information to determine recurrence of SVT within 48 hours. Patient factors including age, sex, medical comorbidities, presence of intercurrent illness, medications and interventions performed, transfer status from an outside facility, and modality of transfer were extracted from the medical record.\u003c/p\u003e \u003cp\u003eSubjects were defined as receiving \u0026ldquo;additional care\u0026rdquo; if they were 1) admitted for inpatient management or 2) had a change in home antiarrhythmic medication or were started on a new antiarrhythmic medication. The retrospective review of all patients meeting inclusion criteria was performed at a visit-level (i.e. multiple visits for the same patient were analyzed separately), allowing inclusion of patients who were seen in the ED on more than one occasion for SVT. Descriptive statistics are all presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation unless otherwise noted in cases where non-parametric distributions were present.\u003c/p\u003e \u003cp\u003eBivariate logistic regression analysis was performed between all variables in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e (age, home controller medication, medical comorbidities, history of SVT, history of pre-excitation, intercurrent illness, transfer from outside facility, number of adenosine doses prior to arrival, total number of adenosine doses, electrical cardioversion, duration of SVT at the time of evaluation, seen in person by cardiology) and no collinearity was established. Multivariable logistic regression analysis was performed between the primary outcome of meaningful additional care (combined admission to hospital and/or change in cardiac medications) and all patient demographic variables. Significance was set apriori at p\u0026thinsp;\u0026le;\u0026thinsp;0.05 for all statistical comparisons (Prism 9.3.0, GraphPad, San Diego, CA).\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eDemographics and patient characteristics\u003c/h2\u003e \u003cp\u003eOne-hundred and ninety-seven encounters met inclusion criteria with mean age of 7.3\u0026thinsp;\u0026plusmn;\u0026thinsp;6.0 years (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Of those included, 53.7% were female (n\u0026thinsp;=\u0026thinsp;87), 46.9% had non-cardiac medical comorbidities (n\u0026thinsp;=\u0026thinsp;92), 51.5% had a history of SVT previously (n\u0026thinsp;=\u0026thinsp;101), 27.5% were previously on a home-controller medication for SVT (n\u0026thinsp;=\u0026thinsp;54), and 14.8% had a history of pre-excitation (n\u0026thinsp;=\u0026thinsp;29).\u003c/p\u003e \u003cp\u003eOn initial evaluation at the study site, 55 subjects (27.9%) were reported to have an intercurrent illness at the time of presentation. The duration of SVT was less than one hour in 47 subjects (23.8%), between one and four hours in 31 (15.7%), between 4 and twelve hours in 11 (5.6%) and greater than 12 hours in one subject (0.5%). The remaining 90 subjects (45.7%) had unknown duration of symptoms.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of patients meeting inclusion criteria. SVT \u0026ndash; supraventricular tachycardia, IQR \u0026ndash; interquartile range\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall (n\u0026thinsp;=\u0026thinsp;197)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAdmitted to Hospital (n\u0026thinsp;=\u0026thinsp;79)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChange in Cardiac Medication (n\u0026thinsp;=\u0026thinsp;88)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years), median [IQR]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.0 [0.8\u0026ndash;13.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.8 [0.1\u0026ndash;9.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.9 [0.1\u0026ndash;5.3]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of SVT, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e107 (54.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52 (65.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e63 (71.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnder 1 hour\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47 (23.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (17.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (14.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;4 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (15.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (10.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u0026ndash;12 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (5.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (4.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGreater than 12 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical Comorbidities, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92 (46.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (44.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40 (45.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of preexcitation, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (22.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (27.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of SVT, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e101 (49.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (41.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49 (55.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOn controller medication, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54 (27.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (30.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35 (39.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntercurrent Illness, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (27.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (43.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34 (38.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransfer from another facility, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59 (30.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (32.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27 (30.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of adenosine doses prior to arrival, median [IQR]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 [0\u0026ndash;1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 [0\u0026ndash;1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 [0\u0026ndash;1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal number of adenosine doses, median [IQR]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 [0\u0026ndash;2]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 [0\u0026ndash;2]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 [0\u0026ndash;2]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardioversion, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (5.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeen in person by cardiology, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e105 (54.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (63.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56 (63.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eInterventions performed\u003c/h2\u003e \u003cp\u003eAt the time of presentation to the study site, 59 of 197 subjects (29.9%) presented as transfers from another facility. The majority (n\u0026thinsp;=\u0026thinsp;139, 69.0%) did not receive adenosine prior to arrival at the study site after transfer via EMS or outside referral. In total, 87 subjects (44.1%) did not receive any doses of adenosine from prehospital, outside facility, or the study site. Of those who were chemically cardioverted with adenosine, 57 (28.9%) received one dose, 33 (16.8%) received two doses, 18 (9.1%) received three doses, and two (1.0%) received four doses. Six subjects (3.0%) received electrical cardioversion. Six patients (4.3%) arrived via transfer in active SVT.\u003c/p\u003e \u003cp\u003eCardiology was consulted for in-person evaluation in the pediatric ED in 105 cases (53.3%). Baseline characteristics of those evaluated by cardiology vs not evaluated were compared (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The median age of those evaluated by cardiology was 5 years compared to 10 years in those not evaluated in person (p\u0026thinsp;=\u0026thinsp;0.0047). A smaller percentage (45%) of those evaluated by cardiology had a history of SVT compared to those not evaluated (54%) (p\u0026thinsp;=\u0026thinsp;0.013). One-hundred eighteen subjects (59.9%) were discharged to home from the ED and 79 (40.1%) were admitted to the hospital. A total of 88 children (44.7%) had changes made to their cardiac medication regimen, either in the ED or after admission. The combined outcome of admission to the hospital or change in cardiac medications occurred in 104 visits (52.8%). Of the 93 subjects discharged without medication changes, two (2.0%) returned to the ED within 48 hours with recurrence of SVT.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of patients seen by cardiology in person versus not seen by cardiology in person\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot evaluated by cardiology (n\u0026thinsp;=\u0026thinsp;89)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEvaluated by cardiology (n\u0026thinsp;=\u0026thinsp;105)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years), median [IQR]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.0 [1.5\u0026ndash;14.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.0 [0.21\u0026ndash;11.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0047\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of SVT, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (50.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60 (57.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnder 1 hour\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (28.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;4 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (15.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (16.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u0026ndash;12 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (5.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGreater than 12 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical Comorbidities, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (46.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49 (46.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of preexcitation, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (12.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (17.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of SVT, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54 (60.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45 (42.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.013\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOn controller medication, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (33.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (22.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntercurrent Illness, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (24.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (30.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransfer from another facility, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (24.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (36.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.078\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of adenosine doses prior to arrival, median [IQR]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 [0\u0026ndash;1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 [0\u0026ndash;1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal number of adenosine doses, median [IQR]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 [0\u0026ndash;1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 [0\u0026ndash;2]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.065\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardioversion, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdmitted to hospital, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (30.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (47.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChange in home controller medication, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (36.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56 (53.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOf subjects transferred from a referring facility (n\u0026thinsp;=\u0026thinsp;59), 26 (44.1%) were admitted to the hospital. Five children (8.5%) underwent changes to their cardiac medications and were subsequently discharged home from the pediatric ED. The remaining patients (n\u0026thinsp;=\u0026thinsp;28, 47.5%) who presented as transfers were discharged to home with no changes in cardiac medications. Of these, (n\u0026thinsp;=\u0026thinsp;19, 67.9%) were evaluated by cardiology.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003eMultivariable Logistic Regression\u003c/h2\u003e \u003cp\u003eA multivariable logistic regression model was created with the primary outcome of combined admission to the hospital and/or change in cardiac medication (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Patient factors significantly associated with the primary outcome included age (aOR 0.77, 95% CI 0.67\u0026ndash;0.86), history of pre-excitation (aOR 5.82, 95% CI 2.01\u0026ndash;18.8), intercurrent illness (aOR 3.75, 95% CI 1.27\u0026ndash;12.1), number of adenosine doses prior to arrival (aOR 5.45, 95% CI 1.55\u0026ndash;22.3), and in- person cardiology consultation (aOR 6.42, 95% CI 2.43\u0026ndash;19.4). The overall area under the curve of the predictive model was 0.92 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) with a negative predictive value of 85.1% and a positive predictive value of 81%.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResults of multivariable regression analysis with combined endpoint of admission to hospital or change in controller medication.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient Factor (n\u0026thinsp;=\u0026thinsp;197)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eaOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.67\u0026ndash;0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of SVT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.48\u0026ndash;1.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical Comorbidities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.35\u0026ndash;5.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of preexcitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.01\u0026ndash;18.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0016\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of SVT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.18\u0026ndash;3.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOn controller medication at home\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.66\u0026ndash;13.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntercurrent Illness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.27\u0026ndash;12.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.020\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransfer from another facility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.16\u0026ndash;1.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of adenosine doses prior to arrival\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.55\u0026ndash;22.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.013\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal number of adenosine dose\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.58\u0026ndash;1.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElectrical Cardioversion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.10\u0026ndash;3.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeen in person by cardiology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.43\u0026ndash;19.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe results of the present study indicate that a majority (59%) of patients were discharged to home without a change to their cardiac medications after pediatric ED management of SVT. Previous research has demonstrated wide variation in admissions ranging from 19\u0026ndash;85% at comparable children\u0026rsquo;s EDs nationwide [2]. To our knowledge, this is the first study evaluating patients undergoing changes to cardiac medications as a primary outcome. Multiple factors were found to be significantly associated with admission or change in cardiac medication.\u003c/p\u003e \u003cp\u003eYounger age was associated with receiving additional care in this study. Younger patients (\u0026lt;\u0026thinsp;1-year-old) have a higher risk of SVT, and previous literature has shown that younger patients are less responsive to adenosine [7]. Additionally, limited history in younger children make it challenging to determine the duration of SVT and gauge their risk of heart failure [8].\u003c/p\u003e \u003cp\u003eA history of pre-excitation was found to be significantly associated with need for admission or change in cardiac medication in this study. Underlying conditions, such as Wolff-Parkinson-White Syndrome, have been estimated to carry a lifetime mortality rate of 3\u0026ndash;4% [9]. Clinicians likely view instances of tachyarrhythmias in these patients as higher risk and therefore warrant additional monitoring. Patients with Wolff-Parkinson-White Syndrome also have a higher risk of recurrent SVT, perhaps influencing cardiologists to more closely adjust their medications if discharged.\u003c/p\u003e \u003cp\u003eThe presence of an intercurrent illness was also associated with admission to the hospital or change in cardiac medication. Acute illness is a known trigger of SVT in those prone to the condition. It is unclear from the data if these patients are admitted due to the acute illness or because SVT is viewed as a disease severity marker.\u003c/p\u003e \u003cp\u003ePatients receiving multiple doses of adenosine, representing refractory SVT, are likely to need prolonged critical care treatment time. We found that patients receiving additional doses of adenosine were more likely to be admitted to the hospital, likely due to concern for recurrence from the managing medical team. Further research is needed to determine if refractory SVT is associated with recurrence.\u003c/p\u003e \u003cp\u003eIn person evaluation by a cardiologist was also associated with admission or discharge with medication changes. Patients evaluated by cardiology were younger, in part explaining this difference. Interestingly, cardiology evaluated in person a higher percentage of patients without a history of SVT. Perhaps this is again explained by younger age where evaluation of infants with first time SVT will not carry a prior diagnosis. Additionally, patients who were evaluated by cardiology likely represent more complex cases and are more likely to be admitted to the hospital or have medication changes. Interestingly, factors such as time of day of arrival, distance traveled, transfer status, and air ambulance transfer were not associated with increased care. It may be interpreted that momentum at the time of transfer does not dictate care received after arrival. However, it does underscore the importance of critically evaluating these transfers as patients were often discharged after consultation with cardiology. This presents a unique opportunity for transfer centers to improve care by offering cardiology consultation to referring institutions.\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eThis is a single center study. As previously discussed, management of SVT is variable across sites and throughout the country, therefore the local practices reported in this study may not apply to every region. An additional limitation is the ease of pediatric cardiology consultation, which may increase the rate of which this consultation is obtained at the tertiary care center studied. Further, this study describes associations with receiving additional care, but we cannot determine how this care affects patient outcomes. A prospective quality improvement project looking at telemedicine and virtual consultation instead of transfer to a tertiary center for patients with SVT is currently underway.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eNearly half of children treated in a pediatric ED for SVT are discharged without changes in medications. Younger age, receiving multiple doses of adenosine, history of preexcitation, intercurrent illness, and in-person cardiology consultation are associated with hospital admission or antiarrhythmic medication changes. These factors represent high value care and can be assessed when considering transfer from a referring facility. Risk stratification using these patient characteristics may reduce potentially avoidable transfers and admissions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Kyle Schmucker, Caroline Morris, Jennifer Dunnick, and Robert Tisherman. The first draft of the manuscript was written by Kyle Schmucker and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompliance with Ethical Standards\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone of the authors have competing interests or funding to disclose. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis retrospective chart review study involving human participants was in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The Human Investigation Committee (IRB) of The University of Pittsburgh approved this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eReyes G, Stanton R, Galvis AG. Adenosine in the treatment of paroxysmal supraventricular tachycardia in children. \u003cem\u003eAnn Emerg Med\u003c/em\u003e. 1992;21(12):1499-1501. doi:10.1016/s0196-0644(05)80069-1\u003c/li\u003e\n\u003cli\u003ePrzybylski R, Michelson KA, Neuman MI, Porter JJ, Alexander ME, Lyons TW. Care of Children with Supraventricular Tachycardia in the Emergency Department. \u003cem\u003ePediatr Cardiol\u003c/em\u003e. 2021;42(3):569-577. doi:10.1007/s00246-020-02515-8\u003c/li\u003e\n\u003cli\u003eD\u0026iacute;az-Parra S, S\u0026aacute;nchez-Ya\u0026ntilde;ez P, Zabala-Arg\u0026uuml;elles I, et al. Use of adenosine in the treatment of supraventricular tachycardia in a pediatric emergency department. \u003cem\u003ePediatr Emerg Care\u003c/em\u003e. 2014;30(6):388-393. doi:10.1097/PEC.0000000000000144\u003c/li\u003e\n\u003cli\u003eVarma S, Schinasi DA, Ponczek J, et al. A Retrospective Study of Children Transferred from General Emergency Departments to a Pediatric Emergency Department: Which Transfers Are Potentially Amenable to Telemedicine? \u003cem\u003eJ Pediatr\u003c/em\u003e. 2021;230:126-132.e1. doi:10.1016/j.jpeds.2020.10.070\u003c/li\u003e\n\u003cli\u003eMohr NM, Harland KK, Shane DM, Miller SL, Torner JC. Potentially Avoidable Pediatric Interfacility Transfer Is a Costly Burden for Rural Families: A Cohort Study. \u003cem\u003eAcad Emerg Med\u003c/em\u003e. 2016;23(8):885-894. doi:10.1111/acem.12972\u003c/li\u003e\n\u003cli\u003eOlympia RP, Wilkinson R, Dunnick J, Dougherty BJ, Zauner D. Pediatric Referrals to an Emergency Department From Urgent Care Centers. \u003cem\u003ePediatr Emerg Care\u003c/em\u003e. 2018;34(12):872-877. doi:10.1097/PEC.0000000000000955\u003c/li\u003e\n\u003cli\u003eLewis J, Arora G, Tudorascu DL, Hickey RW, Saladino RA, Manole MD. Acute Management of Refractory and Unstable Pediatric Supraventricular Tachycardia. \u003cem\u003eJ Pediatr\u003c/em\u003e. 2017;181:177-182.e2. doi:10.1016/j.jpeds.2016.10.051\u003c/li\u003e\n\u003cli\u003eSabat\u0026eacute; Rot\u0026eacute;s A, Figueras Coll M, Gran Ipi\u0026ntilde;a F, et al. Supraventricular tachycardia in children from the perspective of a specialised between-hospital transport team. \u003cem\u003eAn Pediatr\u003c/em\u003e. 2020;93(4):236-241. doi:10.1016/j.anpede.2019.12.012\u003c/li\u003e\n\u003cli\u003eMunger TM, Packer DL, Hammill SC, et al. A population study of the natural history of Wolff-Parkinson-White syndrome in Olmsted County, Minnesota, 1953-1989. \u003cem\u003eCirculation\u003c/em\u003e. 1993;87(3):866-873. doi:10.1161/01.cir.87.3.866\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"pediatric-cardiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pedc","sideBox":"Learn more about [Pediatric Cardiology](http://link.springer.com/journal/246)","snPcode":"246","submissionUrl":"https://submission.nature.com/new-submission/246/3","title":"Pediatric Cardiology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"supraventricular tachycardia, emergency department, pediatric, prehospital, transfer","lastPublishedDoi":"10.21203/rs.3.rs-3060936/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3060936/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground\u003c/p\u003e\n\u003cp\u003eSupraventricular tachycardia (SVT) is a relatively frequent diagnosis in the pediatric emergency department (ED). However, there are no consensus guidelines for ED disposition, and there are limited data on ED outcomes. Better understanding of those who are admitted or have antiarrhythmic medication changes may avoid potentially unnecessary transfers or admissions. Our objective was to identify patient factors associated with discharge from the emergency department without medication initiation or modification after management of SVT in the pediatric ED.\u003c/p\u003e\n\u003cp\u003eDesign/Methods\u003c/p\u003e\n\u003cp\u003eA retrospective review of children aged 0-18 years seen in the emergency department for SVT was conducted using electronic medical record data over a ten-year period at a single academic tertiary children’s hospital. Patients with congenital cardiac disease or prior cardiac surgeries were excluded. Multivariable logistic regression analysis was used to determine association between patient factors of interest and the primary outcome of admission and secondary outcome of change to antiarrhythmic medications.\u003c/p\u003e\n\u003cp\u003eResults\u003c/p\u003e\n\u003cp\u003eWe analyzed 197 patients encounters. The mean age was 7 years. Of these 104 (52.8%) were admitted to the hospital or discharged with antiarrhythmic medication changes. This primary outcome was associated with younger age (aOR 0.77, 95% CI 0.67-0.86), history of pre-excitation (aOR 5.82, 95% CI 2.01-18.8), intercurrent illness (aOR 3.75, 95% CI 1.27-12.1), number of adenosine doses prior to arrival (aOR 5.45, 95% CI 1.55-22.3), and in-person cardiology consultation (aOR 6.42, 95% CI 2.43-19.4).\u003c/p\u003e\n\u003cp\u003eConclusions\u003c/p\u003e\n\u003cp\u003eNearly half of children treated in a pediatric ED for SVT are discharged without changes in medications. We identified patient factors associated with hospital admission or antiarrhythmic medication changes. These factors represent high value care and can be assessed when considering transfer from a referring facility. Risk stratification using these patient characteristics may reduce potentially avoidable transfers and admissions.\u003c/p\u003e","manuscriptTitle":"Patient characteristics associated with hospital admission or antiarrhythmic medication changes after emergency department evaluation of supraventricular tachycardia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-06-16 09:44:21","doi":"10.21203/rs.3.rs-3060936/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-07-06T20:56:57+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-06-15T17:54:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"263b1df5-da56-4ae9-a35f-9ddbfa9fd96d","date":"2023-06-15T17:40:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"862acfe3-5df5-425e-8b30-2c009daaf0cd","date":"2023-06-15T14:38:25+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-06-14T16:30:31+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-06-14T12:25:02+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-06-14T12:25:01+00:00","index":"","fulltext":""},{"type":"submitted","content":"Pediatric Cardiology","date":"2023-06-14T04:44:18+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"pediatric-cardiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pedc","sideBox":"Learn more about [Pediatric Cardiology](http://link.springer.com/journal/246)","snPcode":"246","submissionUrl":"https://submission.nature.com/new-submission/246/3","title":"Pediatric Cardiology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"4fd80557-232f-4b5f-a6a0-5a884dc1a382","owner":[],"postedDate":"June 16th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T22:08:48+00:00","versionOfRecord":{"articleIdentity":"rs-3060936","link":"https://doi.org/10.1007/s00246-023-03257-z","journal":{"identity":"pediatric-cardiology","isVorOnly":false,"title":"Pediatric Cardiology"},"publishedOn":"2023-08-10 21:57:36","publishedOnDateReadable":"August 10th, 2023"},"versionCreatedAt":"2023-06-16 09:44:21","video":"","vorDoi":"10.1007/s00246-023-03257-z","vorDoiUrl":"https://doi.org/10.1007/s00246-023-03257-z","workflowStages":[]},"version":"v1","identity":"rs-3060936","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3060936","identity":"rs-3060936","version":["v1"]},"buildId":"cBFmMYwuxLRRLfASyISRj","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}