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Yusuf S, Camp EA, Adekunle-Ojo AO. Characteristics of Admissions from the Pediatric Emergency Department Observation Unit. South Med J 2024; 117:543-548. [PMID: 39227047 DOI: 10.14423/smj.0000000000001734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2024]
Abstract
OBJECTIVE Emergency department observation units (EDOUs) are used to manage common pediatric illnesses and reduce the admission rate to the hospital. Most of these patients require a short duration of observation before a determination can be made whether they need to be admitted to the hospital or safely discharged home. The purpose of this study was to determine the characteristics of admissions from a pediatric EDOU for the top 10 diagnoses admitted to the unit. This will help standardize the disposition of such types of patients from the ED, hence improving the efficiency of the unit. METHODS We did a retrospective surveillance study of admitted patients from 0 to 18 years of age from the EDOU for the top 10 diagnoses. Descriptive data were reported using percentages and medians with interquartile ranges. Pearson χ2 tests were used to determine significant differences (P < 0.05) between the reason for admission and medical history. RESULTS In total, 520 patients were admitted from the EDOU during the study period. The median patient age was 3.39 years, with most being Hispanic and female. The top three primary diagnoses of all admitted patients were cellulitis and abscess, gastroenteritis, and bronchiolitis. Sixty-three percent of all admitted patients had secondary diagnoses. Most of these patients were admitted to the inpatient unit due to progression of the primary condition. CONCLUSIONS The characteristics of admissions from the EDOU may help us to understand historical experience regarding diagnoses, timing, and indications of deterioration, resource utilization, and other metrics that resulted in transfers of EDOU patients to the intensive care unit/operating room/inpatient units.
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Affiliation(s)
- Shabana Yusuf
- From the Department of Pediatrics, Division of Pediatrics Emergency Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston
| | - Elizabeth A Camp
- From the Department of Pediatrics, Division of Pediatrics Emergency Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston
| | - Aderonke O Adekunle-Ojo
- From the Department of Pediatrics, Division of Pediatrics Emergency Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston
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Gatto A, Rivetti S, Capossela L, Pata D, Covino M, Chiaretti A. Utility of a pediatric observation unit for the management of children admitted to the emergency department. Ital J Pediatr 2021; 47:11. [PMID: 33461571 PMCID: PMC7812641 DOI: 10.1186/s13052-021-00959-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 01/04/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Observation Units (OU), as part of emergency department (ED), are areas reserved for short-term treatment or observation of patients with selected diagnoses to determine the need for hospitalization or home referral. METHODS In this retrospective cohort study, we analyzed similarities and differences of children admitted to the pediatric ED of the Fondazione Policlinico Universitario A. Gemelli IRCCS hospital in the first 2 years of OU activity, analyzing general patient characteristics, access modalities, diagnosis, triage, laboratory and instrumental examinations, specialist visits, outcome of OU admission and average time spent in OU. Furthermore, we compared total numbers and type of hospitalization of the first 2 years of OU activity with those of previous 2 years. RESULTS The most frequent diagnoses were abdominal pain, minor head injury without loss of consciousness, vomiting, epilepsy and acute bronchiolitis. The most performed laboratory examinations were blood count. The most commonly performed instrumental examination was abdominal ultrasound. Neurological counseling was the most commonly requested. Average time spent in OU was 13 h in 2016 and 14.1 h in 2017. Most OU admissions did not last longer than 24 h (90.5% in 2016 and 89.5% in 2017). In the years 2014-2015, 13.4% of pediatric patients accessing the ED were hospitalized, versus 9.9% the years 2016-2017 reducing pediatric hospital admissions by 3.6% (p < 0.001). CONCLUSIONS This study demonstrate that OU is a valid alternative to ordinary wards for specific pathologies. In accordance with the literature, our study showed that, in the first 2 years of the OU activity, admissions to hospital ward decreased compared with the previous 2 years with an increase of complex patients.
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Affiliation(s)
- Antonio Gatto
- Institute of Pediatrics, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli, 00168, Rome, Italy.
| | - Serena Rivetti
- Institute of Pediatrics, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Rome, Italy
| | - Lavinia Capossela
- Institute of Pediatrics, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Rome, Italy
| | - Davide Pata
- Institute of Pediatrics, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Rome, Italy
| | - Marcello Covino
- Department of Emergency, Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Rome, Italy
| | - Antonio Chiaretti
- Institute of Pediatrics, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Rome, Italy
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Borensztajn DM, Hagedoorn NN, Rivero Calle I, Maconochie IK, von Both U, Carrol ED, Dewez JE, Emonts M, van der Flier M, de Groot R, Herberg J, Kohlmaier B, Lim E, Martinon-Torres F, Nieboer D, Nijman RG, Pokorn M, Strle F, Tsolia M, Vermont C, Yeung S, Zavadska D, Zenz W, Levin M, Moll HA. Variation in hospital admission in febrile children evaluated at the Emergency Department (ED) in Europe: PERFORM, a multicentre prospective observational study. PLoS One 2021; 16:e0244810. [PMID: 33411810 PMCID: PMC7790386 DOI: 10.1371/journal.pone.0244810] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 12/16/2020] [Indexed: 11/18/2022] Open
Abstract
Objectives Hospitalisation is frequently used as a marker of disease severity in observational Emergency Department (ED) studies. The comparison of ED admission rates is complex in potentially being influenced by the characteristics of the region, ED, physician and patient. We aimed to study variation in ED admission rates of febrile children, to assess whether variation could be explained by disease severity and to identify patient groups with large variation, in order to use this to reduce unnecessary health care utilization that is often due to practice variation. Design MOFICHE (Management and Outcome of Fever in children in Europe, part of the PERFORM study, www.perform2020.org), is a prospective cohort study using routinely collected data on febrile children regarding patient characteristics (age, referral, vital signs and clinical alarming signs), diagnostic tests, therapy, diagnosis and hospital admission. Setting and participants Data were collected on febrile children aged 0–18 years presenting to 12 European EDs (2017–2018). Main outcome measures We compared admission rates between EDs by using standardised admission rates after adjusting for patient characteristics and initiated tests at the ED, where standardised rates >1 demonstrate higher admission rates than expected and rates <1 indicate lower rates than expected based on the ED patient population. Results We included 38,120 children. Of those, 9.695 (25.4%) were admitted to a general ward (range EDs 5.1–54.5%). Adjusted standardised admission rates ranged between 0.6 and 1.5. The largest variation was seen in short admission rates (0.1–5.0), PICU admission rates (0.2–2.2), upper respiratory tract infections (0.4–1.7) and fever without focus (0.5–2.7). Variation was small in sepsis/meningitis (0.9–1.1). Conclusions Large variation exists in admission rates of febrile children evaluated at European EDs, however, this variation is largely reduced after correcting for patient characteristics and therefore overall admission rates seem to adequately reflect disease severity or a potential for a severe disease course. However, for certain patient groups variation remains high even after adjusting for patient characteristics.
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Affiliation(s)
- Dorine M. Borensztajn
- Department of General Paediatrics, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
- * E-mail:
| | - Nienke N. Hagedoorn
- Department of General Paediatrics, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Irene Rivero Calle
- Genetics, Vaccines, Infections and Pediatrics Research Group (GENVIP), Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Ian K. Maconochie
- Section of Paediatric Infectious Diseases, Imperial College of Science, Technology and Medicine, London, United Kingdom
| | - Ulrich von Both
- Division of Paediatric Infectious Diseases, Dr. von Hauner Children's Hospital, University Hospital, Ludwig, Ludwig-Maximilians-Universität (LMU), München, Germany
| | - Enitan D. Carrol
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Juan Emmanuel Dewez
- Faculty of Tropical and Infectious Disease, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Marieke Emonts
- Great North Children’s Hospital, Paediatric Immunology, Infectious Diseases & Allergy, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
- NIHR Newcastle Biomedical Research Centre Based at Newcastle upon Tyne Hospitals NHS Trust and Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Michiel van der Flier
- Pediatric Infectious Diseases and Immunology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
- Pediatric Infectious Diseases and Immunology, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Laboratory Medicine, Section Pediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud Institute for Molecular Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ronald de Groot
- Stichting Katholieke Universiteit, Radboudumc Nijmegen, Nijmegen, The Netherlands
| | - Jethro Herberg
- Section of Paediatric Infectious Diseases, Imperial College of Science, Technology and Medicine, London, United Kingdom
| | - Benno Kohlmaier
- Department of General Paediatrics, Medical University of Graz, Graz, Austria
| | - Emma Lim
- Great North Children’s Hospital, Paediatric Immunology, Infectious Diseases & Allergy, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Federico Martinon-Torres
- Genetics, Vaccines, Infections and Pediatrics Research Group (GENVIP), Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Daan Nieboer
- Department of Public Health, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ruud G. Nijman
- Section of Paediatric Infectious Diseases, Imperial College of Science, Technology and Medicine, London, United Kingdom
| | - Marko Pokorn
- Department of Infectious Diseases, University Medical Centre Ljubljana, Univerzitetni Klinični Center, Ljubljana, Slovenia
| | - Franc Strle
- Department of Infectious Diseases, University Medical Centre Ljubljana, Univerzitetni Klinični Center, Ljubljana, Slovenia
| | - Maria Tsolia
- Second Department of Paediatrics, National and Kapodistrian University of Athens, P. and A. Kyriakou Children’s Hospital, Athens, Greece
| | - Clementien Vermont
- Department Pediatric Infectious Diseases & Immunology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Shunmay Yeung
- Faculty of Tropical and Infectious Disease, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Dace Zavadska
- Department of Pediatrics, Rīgas Stradiņa Universitāte, Children Clinical University Hospital, Riga, Latvia
| | - Werner Zenz
- Department of General Paediatrics, Medical University of Graz, Graz, Austria
| | - Michael Levin
- Section of Paediatric Infectious Diseases, Imperial College of Science, Technology and Medicine, London, United Kingdom
| | - Henriette A. Moll
- Department of General Paediatrics, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
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Lim CAE, Oh J, Eiting E, Coughlin C, Calderon Y, Barnett B. Development of a combined paediatric emergency department and observation unit. BMJ Open Qual 2020. [PMCID: PMC7011886 DOI: 10.1136/bmjoq-2019-000688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Recent trends towards more cost-efficient and patient-centred treatment are converging to provide opportunities to improve the care of children. Observation units are hospital areas dedicated to the ongoing evaluation and management of patients for a brief period of time for well-defined conditions. We describe the implementation of a paediatric observation unit (POU) adjacent to a paediatric emergency department (PED) in an urban, academic, community hospital. Methods Staffing models were designed to provide paediatric services to patients in both the PED and POU. Admission criteria, workflow and transfer guidelines were developed. Quality improvement initiatives were undertaken and evaluated. Unit throughput, patient outcomes and patient satisfaction data were collected and analysed. Results Over a 2-year period, there were 24 038 patient visits to the PED. Of these, 1215 (5.1%) patients required admission. Seven hundred and seventy-seven (64.0%) of these children were admitted to the POU. One hundred and nineteen (15.3%) of these patients were subsequently converted to inpatient hospitalisation. The average length of stay (LOS) was 25.7 hours in 2017 and 26.5 hours in 2018. Ten patients returned to the PED within 72 hours of discharge from the POU and four were readmitted. Patient satisfaction scores regarding ‘likelihood to recommend’ improved from the 36th to the 92nd percentile rank over a 1-year period. Close monitoring of patient outcomes allowed for the adjustment of admission guidelines, increased unit census and optimised utilisation. Conclusion A combined PED-POU has been successful at our institution in meeting benchmark goals set for LOS and conversion rates. In addition, quality improvement interventions increased patient census and improved patient satisfaction scores while reducing the inpatient burden on the referring children’s hospital.
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Affiliation(s)
- Czer Anthoney Enriquez Lim
- Department of Emergency Medicine, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Pediatrics, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Julie Oh
- Department of Emergency Medicine, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Pediatrics, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Erick Eiting
- Department of Emergency Medicine, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Catherine Coughlin
- Department of Emergency Medicine, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Yvette Calderon
- Department of Emergency Medicine, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Barbara Barnett
- Department of Emergency Medicine, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Simmonds JC, Tuomi A, Groblewski JC. High rates of subglottic stenosis seen in African-American children admitted with severe croup to hospitals in the United States between 2003 and 2013. Respir Med 2018; 143:56-60. [DOI: 10.1016/j.rmed.2018.08.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/27/2018] [Accepted: 08/28/2018] [Indexed: 12/14/2022]
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Chan CM, Wong MY, Chan SL, Wan MY, Mo YF. The Efficacy of Emergency Medicine Ward for the Management of Patients with Mental Disorders. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790901600404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective Patients with mental disorders are one of the target groups selected for management in the Emergency Medicine Ward (EMW) with the enrolment of psychiatric advanced practice nurses. This study aimed to determine whether the EMW can be efficiently used for the management of patients with mental disorders in terms of length of stay (LOS), admission rate, and re-attendance rate when compared with the medical ward. Methods This was a retrospective descriptive study. Patients with mental disorders were defined and recruited from the Princess Margaret Hospital during two selected study periods: pre-opening (pre-EMW) and post-opening (post-EMW) of the EMW. All emergency department records of patients with mental disorders within these two periods were reviewed and data of the selected samples were retrieved from different computer databases. Results The total number of patients with mental disorders was 565 in the pre-EMW period and 404 in the post-EMW period; 214 (37.9%) cases were admitted into the medical ward in the pre-EMW period while only 62 (15.3%) were admitted into the medical ward in the post-EMW period. The mean LOS in the pre-EMW period was 67.7 hours. For the post-EMW period, the mean LOS was 32.3 hours. The reduction in mean LOS was 35.4 hours, and 82% of the study patients treated in the EMW were discharged within 48 hours. Notably, 23.3% of the cases re-attended the emergency department after discharge from the medical ward, whereas only 8.8% of cases re-attended after discharge from the EMW. Conclusion Patients with mental disorders or related problems can be efficaciously managed in the EMW, as evidenced by a decrease in the length of stay, admission rate, and re-attendance rate.
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Affiliation(s)
| | - MY Wong
- Yan Chai Hospital, Accident and Emergency Department, 7–11 Yan Chai Street, Tsuen Wan, N.T., Hong Kong
| | | | | | - YF Mo
- St. John Hospital, Accident and Emergency Department, Cheung Chau Hospital Road, Tung Wan, Cheung Chau, Hong Kong
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Management of Pediatric Isolated Skull Fractures: A Decision Tree and Cost Analysis on Emergency Department Disposition Strategies. Pediatr Emerg Care 2017; 34:403-408. [PMID: 29189590 DOI: 10.1097/pec.0000000000001324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Pediatric isolated skull fractures (ISFs) are common injuries that represent challenging disposition decisions for clinicians. The purpose of this study is to use a decision analysis to compare the clinical and cost-effectiveness of 3 emergency department (ED)-based disposition scenarios for a pediatric patient presenting with ISF. METHODS We conducted a cost-effectiveness analysis comparing ED disposition scenarios that included current practice, increased at-home surveillance, and observation unit utilization. Current rates of admission, deterioration after initial diagnosis, and ED return after discharge, as well as cost of observation-only status, were obtained through literature review. Cost calculations using Healthcare Cost and Utilization Project data included total ED cost, admission without complication, and admission with deterioration. RESULTS In current practice, 76% of subjects with ISF are admitted and 2.5% of those develop persistent or new symptoms. No patient diagnosed with ISF required neurosurgical intervention. Of those discharged home from the ED, 2.8% return with a new concern with 7.4% having new findings on imaging leading to admission. Total cost per 100 patients by current practice was US $583,587. Increasing at-home surveillance by 20% resulted in a total cost saving of US $113,176 per 100 patients while increasing returns to the ED from less than 1% to 1.1%. Admitting at the current rate to an observation unit resulted in a US $205,395 cost saving per 100 patients. CONCLUSIONS Decreased inpatient utilization through home surveillance or observation unit use reduced cost associated with pediatric ISF management without increasing clinical risk owing to the low probability of clinical deterioration after initial diagnosis.
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9
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Abetz JW, Adams NG, Newnham H, Smit DV, Mitra B. Transfer of care and overstay in the management of cellulitis in the emergency short stay unit: A retrospective cohort study. Emerg Med Australas 2017; 29:143-148. [DOI: 10.1111/1742-6723.12731] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 12/01/2016] [Accepted: 12/15/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Jeremy W Abetz
- Emergency and Trauma Centre; The Alfred Hospital; Melbourne Victoria Australia
- Department of Epidemiology and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences; Monash University; Melbourne Victoria Australia
- National Trauma Research Institute; The Alfred Hospital; Melbourne Victoria Australia
| | - Nicholas G Adams
- Emergency and Trauma Centre; The Alfred Hospital; Melbourne Victoria Australia
| | - Harvey Newnham
- General Medicine Unit; The Alfred Hospital; Melbourne Victoria Australia
| | - De Villiers Smit
- Emergency and Trauma Centre; The Alfred Hospital; Melbourne Victoria Australia
| | - Biswadev Mitra
- Emergency and Trauma Centre; The Alfred Hospital; Melbourne Victoria Australia
- Department of Epidemiology and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences; Monash University; Melbourne Victoria Australia
- National Trauma Research Institute; The Alfred Hospital; Melbourne Victoria Australia
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Blecker S, Gavin NP, Park H, Ladapo JA, Katz SD. Observation Units as Substitutes for Hospitalization or Home Discharge. Ann Emerg Med 2015; 67:706-713.e2. [PMID: 26619756 DOI: 10.1016/j.annemergmed.2015.10.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 09/24/2015] [Accepted: 10/21/2015] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE Observation unit admissions have been increasing, a trend that will likely continue because of recent changes in reimbursement policies. The purpose of this study is to determine the effect of the availability of observation units on hospitalizations and discharges to home for emergency department (ED) patients. METHODS We studied ED visits with a final diagnosis of chest pain in the National Hospital Ambulatory Medical Care Survey from 2007 to 2010. ED visits that resulted in an observation unit admission were propensity-score matched to visits at hospitals without an observation unit. We used logistic regression to develop a prediction model for hospitalization versus discharge home for matched patients treated at nonobservation hospitals. The model was applied to matched observation unit patients to determine the likely alternative disposition had the observation unit not been available. RESULTS There were 1,325 eligible visits that represented 5,079,154 visits in the United States. Two hundred twenty-seven visits resulted in an observation unit admission. The predictive model for hospitalization had a c statistic of 0.91; variables significantly associated with subsequent hospitalization included age, history of coronary atherosclerosis, systolic blood pressure less than 115 beats/min, and administration of antianginal medications. When the model was applied to matched observation unit patients, 49.9% of them were categorized as discharge home likely. CONCLUSION In this study, we estimated that half of ED visits for chest pain that resulted in an observation unit admission were made by patients who may have been discharged home had the observation unit not been available. Increased availability of observation units may result in both decreased hospitalizations and decreased discharges to home.
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Affiliation(s)
- Saul Blecker
- Department of Population Health, NYU School of Medicine, New York, NY; Department of Medicine, NYU School of Medicine, New York, NY.
| | - Nicholas P Gavin
- Department of Emergency Medicine, NYU School of Medicine, New York, NY
| | - Hannah Park
- Department of Population Health, NYU School of Medicine, New York, NY
| | - Joseph A Ladapo
- Department of Population Health, NYU School of Medicine, New York, NY; Department of Medicine, NYU School of Medicine, New York, NY
| | - Stuart D Katz
- Department of Medicine, NYU School of Medicine, New York, NY
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Longhi R, Picchi R, Minasi D, Di Cesare Merlone A. Pediatric emergency room activities in Italy: a national survey. Ital J Pediatr 2015; 41:77. [PMID: 26472091 PMCID: PMC4608128 DOI: 10.1186/s13052-015-0184-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 10/01/2015] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND In Italy, the number of accesses to the Emergency Units has been growing for the past 30 years. This, together with a low coordination between hospital and peripheral pediatric services, has brought to an unnecessarily high number of hospital admissions. For this reason, it is essential to plan and implement strategies able to improve the appropriateness of hospital admissions. In the '90s, the Short Stay Observation was extended to pediatric patients. As highlighted by the report "Guidelines for Pediatric Observation Units" (2005), patients receive considerable benefits from a short hospital permanence. The purpose of the study is to report data about the Pediatric Emergency Room activities in Italy. METHODS In 2011, the Italian Society of Pediatrics promoted an online data collection to investigate organization and activity of Italian Pediatric and Neonatal Units. A form, containing 140 questions, was sent to 624 Pediatric and Neonatology Units. This study will be focused only on data regarding pediatric Emergency Rooms (E.R.) and Observation Units. RESULTS 237 units replied, 183 if we focus on units with pediatric inpatient service. Based on the results, E.R Units were provided with a dedicated pediatrician in 56 % of the cases: of these, 85 % for 24 h. The majority of the patients were seen by a pediatrician. In only 8 % of the units, patients visited by a pediatrician were less than 40 %. The age limit was 14 years in 60 % of the cases. In 72 % of participating units a E.R. triage was carried out. Only 18 % of units registered more than 10000 E.R. visits/year. The percentage of children hospitalized after accessing the E.R. was significantly higher in southern regions (more than 20 % of the units hospitalized more than 40 % of children entering the E.R.). 66 % of the units were provided with an Observation Unit. In 61 % of the cases, the duration did not exceed 24 h. In more than half of the structures, less than 10 % of the E.R. visits went into observation. The type of remuneration was not homogeneous. CONCLUSIONS The study highlights the heterogeneity of the Italian reality, with great possibilities for improvement, especially in southern regions.
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Affiliation(s)
- Riccardo Longhi
- Unità Operativa di Pediatria, Ospedale Sant'Anna, San Fermo della Battaglia, Como, Italy.
| | - Raffaella Picchi
- Unità Operativa di Pediatria, Ospedale Sant'Anna, San Fermo della Battaglia, Como, Italy.
| | - Domenico Minasi
- Unità Operativa di Pediatria, Ospedale di Polistena, Reggio Calabria, Italy.
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Shanley LA, Hronek C, Hall M, Alpern ER, Fieldston ES, Hain PD, Shah SS, Macy ML. Structure and Function of Observation Units in Children's Hospitals: A Mixed-Methods Study. Acad Pediatr 2015; 15:518-25. [PMID: 26344718 DOI: 10.1016/j.acap.2014.12.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 12/08/2014] [Accepted: 12/10/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Observation unit (OU) use has been promoted recently to decrease resource utilization and costs for select patients, but little is known about the operations of pediatric OUs. This study aimed to characterize the infrastructure and function of OUs within freestanding children's hospitals and to compare characteristics between hospitals with and without OUs. METHODS All 43 freestanding children's hospitals that submit data to the Pediatric Health Information System were contacted in 2013 to identify OUs that admitted unscheduled patients from their emergency department (ED) in 2011. Semistructured interviews were conducted with representatives at hospitals with these OUs. Characteristics of hospitals with and without OUs were compared. RESULTS Fourteen (33%) of 43 hospitals had an OU during 2011. Hospitals with OUs had more beds and more annual ED visits compared to those without OUs. Most OUs (65%) were located in the ED and had <12 beds (65%). Staffing models and patient populations differed between OUs. Nearly 60% were hybrid OUs, providing scheduled services. OUs lacked uniform outcome measures. Themes included: admissions were intuition based, certain patients were not well suited for OUs, OUs had rapid-turnover cultures, and the designation of observation status was arbitrary. Challenges included patient discontent with copayments and payer-driven utilization reviews. CONCLUSIONS OUs were located in higher volume hospitals and varied by location, size, and staffing. Most functioned as hybrid OUs. OUs based admissions on intuition, had staffing cultures centered on rapid turnover of patient care, lacked consistent outcome measures, and faced challenges regarding utilization review and patient copayments.
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Affiliation(s)
- Leticia A Shanley
- Department of Pediatrics, Children's Medical Center of Dallas, University of Texas Southwestern Medical Center, Dallas, Tex.
| | - Carla Hronek
- Children's Hospital Association, Overland Park, Kans
| | - Matthew Hall
- Children's Hospital Association, Overland Park, Kans
| | - Elizabeth R Alpern
- Department of Pediatrics, Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Evan S Fieldston
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Paul D Hain
- Department of Pediatrics, Children's Medical Center of Dallas, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Samir S Shah
- Department of Pediatrics, Cincinnati Children's Hospital and Medical Center, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Michelle L Macy
- Departments of Emergency Medicine and Pediatrics, Child Health Evaluation and Research (CHEAR) Unit, University of Michigan Medical School, Ann Arbor, Mich
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Macy ML, Hall M, Alpern ER, Fieldston ES, Shanley LA, Hronek C, Hain PD, Shah SS. Observation-status patients in children's hospitals with and without dedicated observation units in 2011. J Hosp Med 2015; 10:366-72. [PMID: 25755175 DOI: 10.1002/jhm.2339] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 02/09/2015] [Accepted: 02/10/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND Pediatric observation units (OUs) have demonstrated reductions in lengths of stay (LOS) and costs of care. Hospital-level outcomes across all observation-status stays have not been evaluated in relation to the presence of a dedicated OU in the hospital. OBJECTIVE To compare observation-status stay outcomes in hospitals with and without a dedicated OU. DESIGN Cross-sectional analysis of hospital administrative data. METHODS Observation-status stay outcomes were compared in hospitals with and without a dedicated OU across 4 categories: (1) LOS, (2) standardized costs, (3) conversion to inpatient status, and (4) return care. SETTING/PATIENTS Observation-status stays in 31 free-standing children's hospitals contributing observation patient data to the Pediatric Health Information System database, 2011. RESULTS Fifty-one percent of the 136,239 observation-status stays in 2011 occurred in 14 hospitals with a dedicated OU; the remainder were in 17 hospitals without. The percentage of observation-status same-day discharges was higher in hospitals with a dedicated OU compared with hospitals without (23.8 vs 22.1, P < 0.001), but risk-adjusted LOS in hours and total standardized costs were similar. Conversion to inpatient status was higher in hospitals with a dedicated OU (11.06%) compared with hospitals without (9.63%, P < 0.01). Adjusted odds of return visits and readmissions were comparable. CONCLUSIONS The presence of a dedicated OU appears to have an influence on same-day and morning discharges across all observation-status stays without impacting other hospital-level outcomes. Inclusion of location of care (eg, dedicated OU, inpatient unit, emergency department) in hospital administrative datasets would allow for more meaningful comparisons of models of hospital care.
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Affiliation(s)
- Michelle L Macy
- Departments of Emergency Medicine and Pediatrics, Child Health Evaluation and Research Unit, University of Michigan Medical School, Ann Arbor, Michigan
| | - Matthew Hall
- Children's Hospital Association, Overland Park, Kansas
| | - Elizabeth R Alpern
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Evan S Fieldston
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Leticia A Shanley
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Paul D Hain
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Samir S Shah
- Department of Pediatrics, Cincinnati Children's Hospital and Medical Center, University of Cincinnati School of Medicine, Cincinnati, Ohio
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Mistry RD, Hirsch AW, Woodford AL, Lundy M. Failure of Emergency Department Observation Unit Treatment for Skin and Soft Tissue Infections. J Emerg Med 2015; 49:855-63. [PMID: 25937477 DOI: 10.1016/j.jemermed.2015.02.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 01/13/2015] [Accepted: 02/17/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The effectiveness of observation unit (OU) management of skin and soft tissue infections (SSTI) has not been fully evaluated. OBJECTIVE This study was performed to determine the rate and risk factors. METHODS Retrospective cohort study of children ages 2 months to 18 years admitted to the OU for an SSTI between 2007 and 2010 from a pediatric emergency department (ED). Failure of OU therapy was defined as subsequent inpatient ward admission, re-admission after discharge from OU, initial or repeat incision and drainage after OU admission, or change in antibiotic therapy. Demographic, clinical, and lesion characteristics were collected. Comparative analyses were conducted to determine factors associated with OU failure; prolonged OU admission, defined as length of stay ≥ 36 h was evaluated. RESULTS One hundred ninety-two (63.2%) of 304 subjects with SSTI were eligible; mean age was 6.2 ± 5.3 years, and 52% were male. Fever (≥38°C) in the ED was present for 77 (40%). Most lesions were skin abscesses (53%) and were located on the lower extremity (36%) and buttock/genitourinary (21%). OU treatment failure occurred in 22% (95% confidence interval [CI] 16.5-28.3), primarily due to inpatient admission. Fever on ED presentation was significantly associated with OU failure (odds ratio 2.02; 95% CI 1.02-4.02). Demographics, body site, presence of abscess, and methicillin-resistant Staphylococcus aureus were not associated with OU failure. Prolonged OU admission occurred in 18 subjects (9.4%). CONCLUSION SSTI can be successfully treated in the OU, though febrile children with SSTI are at risk for OU treatment failure and should be considered for inpatient admission.
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Affiliation(s)
- Rakesh D Mistry
- Department of Pediatrics, Section of Emergency Medicine, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Alexander W Hirsch
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Ashley L Woodford
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Megan Lundy
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Shetty AL, Shankar Raju SB, Hermiz A, Vaghasiya M, Vukasovic M. Age and admission times as predictive factors for failure of admissions to discharge-stream short-stay units. Emerg Med Australas 2014; 27:42-6. [PMID: 25406761 DOI: 10.1111/1742-6723.12329] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Discharge-stream emergency short-stay units (ESSU) improve ED and hospital efficiency. Age of patients and time of hospital presentations have been shown to correlate with increasing complexity of care. We aim to determine whether an age and time cut-off could be derived to subsequently improve short-stay unit success rates. METHODS We conducted a retrospective audit on 6703 (5522 inclusions) patients admitted to our discharge-stream short-stay unit. Patients were classified as appropriate or inappropriate admissions, and deemed successful if discharged out of the unit within 24 h; and failures if they needed inpatient admission into the hospital. We calculated short-stay unit length of stay for patients in each of these groups. A 15% failure rate was deemed as acceptable key performance indicator (KPI) for our unit. RESULTS There were 197 out of 4621 (4.3%, 95% CI 3.7-4.9%) patients up to the age of 70 who failed admission to ESSU compared with 67 out of 901 (7.4%, 95% CI 5.9-9.3%, P < 0.01) of patients over the age of 70, reflecting an increased failure rate in geriatric population. When grouped according to times of admission to the ESSU (in-office 06.00-22.00 hours vs out-of-office 22.00-06.00 hours) no significant difference rates in discharge failure (4.7% vs 5.2%, P = 0.46) were noted. CONCLUSION Patients >70 years of age have higher rates of failure after admission to discharge-stream ESSU. Although in appropriately selected discharge-stream patients, no age group or time-band of presentation was associated with increased failure rate beyond the stipulated KPI.
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Affiliation(s)
- Amith L Shetty
- Emergency Department, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Emergency Medicine Research Unit, Sydney, New South Wales, Australia; NHMRC Centre for Research Excellence in Critical Infection, Westmead Millennium Institute for Medical Research, Sydney, New South Wales, Australia
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Mattsson MS, Mattsson N, Jørsboe HB. Improvement of clinical quality indicators through reorganization of the acute care by establishing an emergency department-a register study based on data from national indicators. Scand J Trauma Resusc Emerg Med 2014; 22:60. [PMID: 25370418 PMCID: PMC4226916 DOI: 10.1186/s13049-014-0060-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 10/08/2014] [Indexed: 11/10/2022] Open
Abstract
Background The Emergency Departments (EDs) reorganization process in Denmark began in 2007 and includes creating a single entrance for all emergency patients, establishing triage, having a specialist in the front and introducing the use of electronic overview boards and electronic patient files. The aim of this study was to investigate the quality of acute care in a re-organized ED based on national indicator project data in a pre and post reorganizational setting. Methods Quasi experimental design was used to examine the effect of the health care quality in relation to the reorganization of an ED. Patients admitted at Nykøbing Falster Hospital in 2008 or 2012 were included in the study and data reports from the national databases (RKKP) regarding stroke, COPD, heart failure, bleeding and perforated ulcer or hip fracture were analysed. Holbæk Hospital works as a control hospital. Chi-square test was used for analysing significant differences from pre-and post intervention and Z-test to compare the experimental groups to the control group (HOL). P < 0.05 was considered statistically significant. Results We assessed 4584 patient cases from RKKP. A significant positive change was seen in all of the additional eight indicators related to stroke at NFS (P < 0.001); however, COPD indicators were unchanged in both hospitals. In NFS two of eight heart failure indicators were significantly improved after the reorganization (p < 0.01). In patients admitted with a bleeding ulcer 2 of 5 indicators were significantly improved after the reorganization in NFS and HOL (p < 0.01). Both compared hospitals showed significant improvements in the two indicators concerning hip fracture (p < 0.001). Significant reductions in the 30 day-mortality in patients admitted with stroke were seen when the pre- and the post-intervention data were compared for both NFS and HOL (p = 0.024). Conclusions During the organisation of the new EDs, several of the indicators improved and the overall 30 days mortality decreased in the five diseases. The development of a common set of indicators for monitoring acute treatment at EDs in Denmark is recommended.
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Affiliation(s)
- Maria Søe Mattsson
- Faculty of Health Science, University of Southern Denmark, 5230, Odense M, Denmark. .,Emergency Department, Hospital of Nykøbing Falster, 4800, Nykøbing Falster, Denmark.
| | - Nick Mattsson
- Emergency Department, Hospital of Nykøbing Falster, 4800, Nykøbing Falster, Denmark. .,Department of Cardiology, Bispebjerg Hospital, 2400, Copenhagen, NV, Denmark.
| | - Hanne B Jørsboe
- Emergency Department, Hospital of Nykøbing Falster, 4800, Nykøbing Falster, Denmark.
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A new charging scheme in an emergency department observation unit under Beijing’s basic medical insurance. Chin Med J (Engl) 2014. [DOI: 10.1097/00029330-201409200-00017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Cator AD, Weber JS, Lozon MM, Macy ML. Effect of using pediatric emergency department virtual observation on inpatient admissions and lengths of stay. Acad Pediatr 2014; 14:510-6. [PMID: 25169162 DOI: 10.1016/j.acap.2014.03.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 03/09/2014] [Accepted: 03/12/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine whether using emergency department (ED) virtual observation for select pediatric conditions decreases admission rates for these conditions, and to examine effects on length of stay. METHODS The option of ED virtual observation care for 9 common pediatric conditions was introduced in 2009; associated order sets were developed. Retrospective secondary analyses of administrative data from our tertiary care pediatric ED and children's hospital were performed for the year before (year 0) and after (year 1) this disposition option was introduced. The proportion of visits admitted to the inpatient unit and length of stay (LOS) were determined for all visits considered eligible for ED virtual observation care on the basis of diagnosis codes for both study years. RESULTS There were 1614 observation-eligible visits in year 0 and 1510 in year 1. In year 1, 18% (n = 266) of observation-eligible visits received ED virtual observation care. Admission rates for observation-eligible visits were similar after this model of care was introduced (25% year 0, 29% year 1, P = .02). Median LOS for ED virtual observation visits was 8.8 hours (interquartile range 6.5-12.4). ED LOS was shorter for ED discharges (5.6 hours year 0, 5.1 hours year 1, P < .001) and unchanged for admissions (6.0 hours year 0, 5.8 hours, year 1, P = .41) after introducing ED virtual observation. CONCLUSIONS Admission rates for observation-eligible visits were not lower in the year after ED virtual observation care was introduced. LOS decreased for ED discharges and was unchanged for admissions. Reevaluation of the effects of pediatric ED virtual observation on admission rates and LOS after longer periods of use is indicated.
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Affiliation(s)
- Allison D Cator
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Mich; Department of Pediatrics, University of Michigan, Ann Arbor, Mich.
| | - Julie S Weber
- Wayne State University School of Medicine, Detroit, Mich
| | - Marie M Lozon
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Mich; Department of Pediatrics, University of Michigan, Ann Arbor, Mich
| | - Michelle L Macy
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Mich; Division of General Pediatrics, Department of Pediatrics, Child Health Evaluation and Research Unit, University of Michigan, Ann Arbor, Mich
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Hockenberry JM, Mutter R, Barrett M, Parlato J, Ross MA. Factors associated with prolonged observation services stays and the impact of long stays on patient cost. Health Serv Res 2013; 49:893-909. [PMID: 24344860 DOI: 10.1111/1475-6773.12143] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Patients are treated using observation services (OS) when their care needs exceed standard outpatient care (i.e., clinic or emergency department) but do not qualify for admission. Medicare and other private payers seek to limit this care setting to 48 hours. DATA SOURCE/STUDY SETTING Healthcare Cost and Utilization Project data from 10 states and data collected from two additional states for 2009. STUDY DESIGN Bivariate analyses and hierarchical linear modeling were used to examine patient- and hospital-level predictors of OS stays exceeding 48 (and 72) hours (prolonged OS). Hierarchical models were used to examine the additional cost associated with longer OS stays. PRINCIPAL FINDINGS Of the 696,732 patient OS stays, 8.8 percent were for visits exceeding 48 hours. Having Medicaid or no insurance, a condition associated with no OS treatment protocol, and being discharged to skilled nursing were associated with having a prolonged OS stay. Among Medicare patients, the mean charge for OS stays was $10,373. OS visits of 48-72 hours were associated with a 42 percent increase in costs; visits exceeding 72 hours were associated with a 61 percent increase in costs. CONCLUSION Patient cost sharing for most OS stays of less than 24 hours is lower than the Medicare inpatient deductible. However, prolonged OS stays potentially increase this cost sharing.
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Affiliation(s)
- Jason M Hockenberry
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA; Center for Comprehensive Access Delivery Research and Evaluation, Iowa City Veterans Health Care System, Atlanta, GA
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Factors associated with prolonged stay in a pediatric emergency observation unit of an urban tertiary children's hospital in China. Pediatr Emerg Care 2013; 29:183-90. [PMID: 23364384 DOI: 10.1097/pec.0b013e3182809b64] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES This study aimed to examine the factors associated with increased length of stay (LOS > 24 hours) in the pediatric emergency observation unit (OU) of an urban tertiary children's hospital in China. METHODS This study was a retrospective cohort study. We retrieved and examined all the records of patients (age, 0-16 years) who were admitted to the OU (n = 10,852) during July 1, 2008, to June 30, 2009. The primary outcome was LOS and prolonged stay (LOS > 24 hours). We also performed a sensitivity analysis by using LOS of 3 days or greater and LOS of 6 days or greater as dependent variables in logistic regression and compared with LOS of greater than 24 hours regression to examine the robustness of the associations. RESULTS The overall mean (SD) LOS was 24.0 (24.4) hours; 31.3% had LOS of greater than 24 hours, of which the mean (SD) LOS was 50.2 (28.6) hours. The following factors were associated with LOS of greater than 24 hours: age, 28 days to 3 months (odds ratio, [OR], 1.87; 95% confidence interval, 1.36-2.59) and older than 3 months to 12 months (OR, 1.83; 95% CI, 1.35-2.50) compared with age 0 to 28 days; neurologic diseases (OR, 1.50; 95% CI, 1.31-1.72), infectious diseases (OR, 2.00; 95% CI, 1.61-2.49), and visits for non-respiratory-related signs and symptoms (OR, 2.00; 95% CI, 1.61-2.49); acuity level of emergent (OR, 1.79; 95% CI, 1.57-2.04); procedures (OR, 7.09; 95% CI, 4.16-12.10); emergency transfusions (OR, 1.33; 95% CI, 1.01-1.75); staffed by residents (OR, 1.12; 95% CI, 1.01-1.24); and patients living in low-annual gross domestic product districts (OR, 1.14; 95% CI, 1.01-1.29). Arrival at evening (OR, 0.54; 95% CI, 0.49-0.60) and overnight (OR, 0.43; 95% CI, 0.38-0.49) were less likely to have LOS of greater than 24 hours than arrival during day shifts. CONCLUSIONS We identified some risk factors for prolonged stay in an OU. These factors are the starting points in understanding issues related to prolonged stay and are needed to assess efficiency and quality of care in pediatric emergency department and OU. Our results have provided information basis for making improvements in the system and may be important considerations for similar institutions, which encounter similar challenges.
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Ross MA, Aurora T, Graff L, Suri P, O'Malley R, Ojo A, Bohan S, Clark C. State of the art: emergency department observation units. Crit Pathw Cardiol 2012; 11:128-38. [PMID: 22825533 DOI: 10.1097/hpc.0b013e31825def28] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Hospitals and emergency departments face the challenges of escalating healthcare costs, mismatched resource utilization, concern over avoidable admissions, and hospital and emergency department overcrowding. One approach that has been used by hospitals to address these issues is the use of emergency department observation units. Research in this setting has increased in recent years, leading to a better understanding of the role of these units and their unique benefits. These benefits have been proven for health systems as a whole and for several acute conditions including chest pain, asthma, syncope, transient ischemic attack, atrial fibrillation, heart failure, abdominal pain, and more. Benefits include a decrease in diagnostic uncertainty, lower cost and resource utilization, improved patient satisfaction, and clinical outcomes that are comparable to admitted patients. As more hospitals begin to use observation units, there is a need for further education and research in how to optimize the use of emergency department observation units. The purpose of this article is to provide a general overview of observation units, including advancements and research in this field.
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Affiliation(s)
- Michael A Ross
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA.
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Clinical assessment of children with first-attack seizures admitted to the ED. Am J Emerg Med 2012; 30:1080-8. [DOI: 10.1016/j.ajem.2011.07.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2011] [Revised: 07/05/2011] [Accepted: 07/13/2011] [Indexed: 11/18/2022] Open
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Emergency department observation units: A clinical and financial benefit for hospitals. Health Care Manage Rev 2012; 36:28-37. [PMID: 21157228 DOI: 10.1097/hmr.0b013e3181f3c035] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
INTRODUCTION There are nearly 120 million visits to emergency departments each year, one for every three people in the United States. Fifty percent of all hospital admissions come from this group, a marked change from the mid-1990s when the emergency department was a source of only a third of admissions. As the population increases and ages, the growth rate for emergency department visits and the resulting admissions will exceed historical trends creating a surge in demand for inpatient beds. BACKGROUND Current health care reform efforts are highlighting deficiencies in access, cost, and quality of care in the United States. The need for more inpatient capacity brings attention to short-stay admissions and whether they are necessary. Emergency department observation units provide a suitable alternate venue for many such patients at lower cost without adversely affecting access or quality. METHODS This article serves as a literature synthesis in support of observation units, with special emphasis on the clinical and financial aspects of their use. The observation medicine literature was reviewed using PubMed, and selected sources were used to summarize the current state of practice. In addition, the authors introduce a novel conceptual framework around measures of observation unit efficiency. FINDINGS AND PRACTICE IMPLICATIONS Observation units provide high-quality and efficient care to patients with common complaints seen in the emergency department. More frequent use of observation can increase patient safety and satisfaction while decreasing unnecessary inpatient admissions and improving fiscal performance for both emergency departments and the hospitals in which they operate. For institutions with the volume to justify the fixed costs of operating an observation unit, the dominant strategy for all stakeholders is to create one.
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Conners GP, Melzer SM, Betts JM, Chitkara MB, Jewell JA, Lye PS, Mirkinson LJ, Shaw KN, Ackerman AD, Chun TH, Conners GP, Dudley NC, Fein JA, Fuchs SM, Moore BR, Selbst SM, Wright JL. Pediatric observation units. Pediatrics 2012; 130:172-9. [PMID: 22732171 DOI: 10.1542/peds.2012-1358] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Pediatric observation units (OUs) are hospital areas used to provide medical evaluation and/or management for health-related conditions in children, typically for a well-defined, brief period. Pediatric OUs represent an emerging alternative site of care for selected groups of children who historically may have received their treatment in an ambulatory setting, emergency department, or hospital-based inpatient unit. This clinical report provides an overview of pediatric OUs, including the definitions and operating characteristics of different types of OUs, quality considerations and coding for observation services, and the effect of OUs on inpatient hospital utilization.
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Macy ML, Hall M, Shah SS, Hronek C, Del Beccaro MA, Hain PD, Alpern ER. Differences in designations of observation care in US freestanding children's hospitals: are they virtual or real? J Hosp Med 2012; 7:287-93. [PMID: 22031487 DOI: 10.1002/jhm.949] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Revised: 05/03/2011] [Accepted: 05/08/2011] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To characterize practices related to observation care and to examine the current models of pediatric observation medicine in US children's hospitals. DESIGN We utilized 2 web-based surveys to examine observation care in the 42 hospitals participating in the Pediatric Health Information System database. We obtained information regarding the designation of observation status, including the criteria used to admit patients into observation. From hospitals reporting the use of observation status, we requested specific details relating to the structures of observation care and the processes of care for observation patients following emergency department treatment. RESULTS A total of 37 hospitals responded to Survey 1, and 20 hospitals responded to Survey 2. Designated observation units were present in only 12 of 31 (39%) hospitals that report observation patient data to the Pediatric Health Information System. Observation status was variably defined in terms of duration of treatment and prespecified criteria. Observation periods were limited to <48 hours in 24 of 31 (77%) hospitals. Hospitals reported that various standards were used by different payers to determine observation status reimbursement. Observation care was delivered in a variety of settings. Most hospitals indicated that there were no differences in the clinical care delivered to virtual observation status patients when compared with other inpatients. CONCLUSIONS Observation is a variably applied patient status, defined differently by individual hospitals. Consistency in the designation of patients under observation status among hospitals and payers may be necessary to compare quality outcomes and costs, as well as optimize models of pediatric observation care.
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Affiliation(s)
- Michelle L Macy
- Department of Emergency Medicine and the Child Health Evaluation and Research Unit, Division of General Pediatrics, University of Michigan, Ann Arbor, Michigan 48109-5456, USA.
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Abstract
BACKGROUND As more efficient and value-based care models are sought for the US healthcare system, geographically distinct observation units (OUs) may become an integral part of hospital-based care for children. PURPOSE To systematically review the literature and evaluate the structure and function of pediatric OUs in the United States. DATA SOURCES Searches were conducted in Medline, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Health Care Advisory Board (HCAB), Lexis-Nexis, National Guideline Clearinghouse, and Cochrane Reviews, through February 2009, with review of select bibliographies. STUDY SELECTION English language peer-reviewed publications on pediatric OU care in the United States. DATA EXTRACTION Two authors independently determined study eligibility. Studies were graded using a 5-level quality assessment tool. Data were extracted using a standardized form. DATA SYNTHESIS A total of 21 studies met inclusion criteria: 2 randomized trials, 2 prospective observational, 12 retrospective cohort, 2 before and after, and 3 descriptive studies. Studies present data on more than 22,000 children cared for in OUs, most at large academic centers. This systematic review provides a descriptive overview of the structure and function of pediatric OUs in the United States. Despite seemingly straightforward outcomes for OU care, significant heterogeneity in the reporting of length of stay, admission rates, return visit rates, and costs precluded our ability to conduct meta-analyses. We propose standard outcome measures and future directions for pediatric OU research. CONCLUSIONS Future research using consistent outcome measures will be critical to determining whether OUs can improve the quality and cost of providing care to children requiring observation-length stays.
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Affiliation(s)
- Michelle L Macy
- Division of General Pediatrics, Child Health Evaluation and Research Unit, University of Michigan, Ann Arbor, Michigan 48109-5456, USA.
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Macy ML, Stanley RM, Lozon MM, Sasson C, Gebremariam A, Davis MM. Trends in high-turnover stays among children hospitalized in the United States, 1993-2003. Pediatrics 2009; 123:996-1002. [PMID: 19255031 PMCID: PMC2746715 DOI: 10.1542/peds.2008-1428] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Brief hospitalizations for children may constitute an opportunity to provide care in an alternative setting such as an observation unit. The goal of this study was to characterize recent national trends in brief inpatient stays for children in the United States. METHODS Using the Nationwide Inpatient Sample from 1993-2003, we analyzed hospital discharges among children <18 years of age, excluding births, deaths, and transfers. Hospitalizations with lengths of stay of 0 and 1 night were designated as "high turnover." Serial cross-sectional analyses were conducted to compare the proportion of high-turnover stays across and within years according to patient and hospital-level characteristics. Diagnosis-related groups and hospital charges associated with these observation-length stays were examined. RESULTS In 2003, there were an estimated 441 363 high-turnover hospitalizations compared with 388 701 in 1993. The proportion of high-turnover stays increased from 24.9% in 1993 to 29.9% in 1999 and has remained >/=30.0% since that time. Diagnosis-related groups for high-turnover stays reflect common pediatric medical and surgical conditions requiring hospitalization, including respiratory illness, gastrointestinal/metabolic disorders, seizure/headache, and appendectomy. Significant increases in the proportion of high-turnover stays during the study period were noted across patient and hospital-level characteristics, including age group, payer, hospital location, teaching status, bed size, and admission source. High-turnover stays contributed $1.3 billion (22%) to aggregate hospital charges in 2003, an increase from $494 million (12%) in 1993. CONCLUSIONS Consistently since 1999, nearly one third of children hospitalized in the United States experience a high-turnover stay. These high-turnover cases constitute hospitalizations, that may be eligible for care in an alternative setting. Observation units provide 1 model for an efficient and cost-effective alternative to inpatient care, in which resources and provider interactions with patients and each other are geared toward shorter stays with more timely discharge processes.
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Affiliation(s)
- Michelle L. Macy
- Child Health Evaluation and Research Unit, Division of General Pediatrics, University of Michigan, Ann Arbor, Michigan, Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
| | - Rachel M. Stanley
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
| | - Marie M. Lozon
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
| | - Comilla Sasson
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
| | - Achamyeleh Gebremariam
- Child Health Evaluation and Research Unit, Division of General Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Matthew M. Davis
- Child Health Evaluation and Research Unit, Division of General Pediatrics, University of Michigan, Ann Arbor, Michigan, Division of Internal Medicine and Gerald R. Ford School of Public Policy, University of Michigan, Ann Arbor, Michigan
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Abstract
BACKGROUND Over the past two decades, the use of observation units to treat such common conditions as chest pain, asthma, and others has greatly increased. These units allow patients to be directed out of emergency department (ED) acute care beds while potentially avoiding inpatient admission. Many studies have demonstrated the clinical effectiveness of care delivered in such a setting compared to the ED or inpatient ward. However, there are limited data published about observation unit finance. METHODS Using the economic principles of stock options, opportunity costs, and net present value (NPV), a model that captures the value generated by admitting a patient to an observation unit was derived. In addition, an appendix is included showing how this model can be used to calculate the dollar value of an observation unit admission. RESULTS A model is presented that captures more complexity of observation finance than the simple difference between payments and costs. The calculated estimate in the Appendix suggests that the average value of a single observation unit admission was about $2,908, which is about 40% higher than expected. CONCLUSION Subtraction of costs from payments may significantly underestimate the financial value of an observation unit admission. However, the positive value generated by an observation unit bed must be considered in the context of other projects available to hospital administrators.
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Affiliation(s)
- Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA.
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29
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Shah SS, Downes KJ, Elliott MR, Bell LM, McGowan KL, Metlay JP. How long does it take to "rule out" bacteremia in children with central venous catheters? Pediatrics 2008; 121:135-41. [PMID: 18166567 DOI: 10.1542/peds.2007-1387] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Children with central venous catheters and suspected bloodstream infection are often hospitalized for 48 hours to receive empiric antibiotic therapy pending blood-culture results. Continuous monitoring blood-culture systems allow for more rapid detection of bloodstream infection than previous blood-culture systems, a feature that may facilitate earlier determination of the true presence or absence of bloodstream infection and shorten empiric antibiotic therapy and duration of hospitalization. METHODS This retrospective cohort study included children with central venous catheters who were diagnosed with laboratory-confirmed bloodstream infection after evaluation in the ambulatory care setting. RESULTS Two-hundred episodes of bloodstream infection were included. The median patient age was 5.5 years. Central venous catheters were in place for a median of 80.5 days. Gram-negative bacteria accounted for 51% of infections as part of either a monomicrobial (25%) or polymicrobial (26%) infection. The overall median time to blood-culture positivity was 14 hours. The predicted probability for a culture being positive at 36 hours was 99.2% for infections caused by gram-negative bacteria and 96.6% for any infection after adjusting for age, catheter type, and recent antibiotic use. In a multivariate Cox proportional-hazards regression model, polymicrobial infections with > or = 1 gram-negative bacteria and monomicrobial infections caused by gram-negative bacteria were independently associated with an earlier time to blood-culture positivity after adjusting for age, catheter type, and recent antibiotic use. CONCLUSIONS The time to blood-culture positivity depends on bacterial category. Bloodstream infections caused by gram-negative bacteria are detected most quickly. Our data suggest that discontinuation of empiric antibiotic coverage may be warranted in clinically stable children with central venous catheters if the blood-culture results remain negative 24 to 36 hours after collection.
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Affiliation(s)
- Samir S Shah
- Children's Hospital of Philadelphia, Division of Infectious Diseases, Room 1526, North Campus, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, USA.
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