523 - Medically Unnecessary & Unethical: Venipuncture for Behavioral Disturbance in Patients with Autism Spectrum Disorder (ASD) Presenting to the Pediatric Emergency Department (ED)

Poster Number: 523
Publication Number: 523.422

Dylan P. Hurley, Center for Ethics, Laney Graduate School, Emory University / Rollins School of Public Health, Emory University, Decatur, GA, United States; Alexis C. Pavlov, Emory University School of Medicine, Atlanta, GA, United States; Amy E. Pattishall, Emory University/Pediatric Institute, Atlanta, GA, United States; Patricia A. Bush, Emory/Children's Healthcare of Atlanta, Atlanta, GA, United States; Nathan Call, Emory University School of Medicine, Atlanta, GA, United States; Claudia R. Morris, Emory University School of Medicine, Atlanta, GA, United States

Background: Children with ASD that present to EDs with behavioral disturbances undergo routine screening lab work. Little is known regarding the clinical significance of this lab work and its use in clinical decision-making during the patient’s stay. Lab draws are viewed as an adverse experience for patients with ASD and often require restraint or mild sedation. Unnecessary venipuncture presents significant ethical considerations for this vulnerable patient population.

Objective: To assess the clinical value of blood specimen collection in the ED evaluation of behavioral disturbances in children with ASD & consider the significant ethical implications for this vulnerable patient population to provide a potential alternative standard of care recommendation for future clinical practice.

Design/Methods: This is a retrospective chart review of patients ages 3-21 years with ASD presenting to 3 pediatric EDs with behavioral disturbances from Jan 2019 - Jan 2020. Patients without an ASD diagnosis were excluded. Local laboratory standards were used to determine abnormal ranges in screening labs obtained in the ED. Patients with abnormal findings were reviewed to determine if the finding was medically significant. Medical significance was defined as the need for a medical intervention, inpatient observation, or the inclusion of a non-behavioral diagnostic code due to an abnormal laboratory test result.

Results: 213 ED encounters were reviewed (Table 1). Of those 213 encounters, 176 (83%) received venipuncture for screening labs. Within these 176 patient visits, 170 (97%) featured abnormal lab test results, of which only 2 abnormal labs (1%) revealed a potentially medically significant finding. One patient presented with a finding of hypokalemia (2.9 mmol/L K) that was 3.9 mmol/L on repeat venipuncture after 40 mEg oral KCL. Another patient presented with an incidental finding of microcytic anemia (7.1 g/dL Hg) and was discharged home with iron supplementation.Conclusion(s): Screening labs for pediatric patients with ASD presenting to the ED with behavioral disturbance are medically unnecessary and a cause for ethical concern. Lab values were often outside the range of normal but not clinically significant and may lead to additional unnecessary testing and therapies. Medically unnecessary interventions in vulnerable populations warrant a need to examine the integration of medical beneficence and non-maleficence in standard of care practices. There is a need for pediatric emergency centers to re-evaluate screening protocols for asymptomatic patients and approaches to treatment of those with ASD.
Demographics & Lab Test Review
Lab Test Breakdown