Observation Unit Management of Pediatric Emergencies

Can the Pediatric Early Warning Score (PEWS) Predict Hospital Length of Stay?

Background: Limited studies have evaluated the utility of scoring systems in the pediatric emergency department (PED) and no studies have evaluated their ability to predict hospital length of stay (LOS) and the usage of Observation units (OUs).

Objective: To evaluate the utility of the Pediatric Early Warning Score (PEWS) in predicting LOS in pediatric patients and thus anticipate admission to an OU versus the pediatric ward.

Methods: A retrospective study of pediatric inpatients (0 to 18 years) at an inner-city community hospital between January 2014 and December 2014. Patients with psychiatric illness, non-medical reasons for hospital stay, and those not discharged to ‘home’ were excluded. Demographic data, PEWS in the ED, and LOS for each patient were recorded and analyzed.

Results: A total of 719 patients were analyzed. PEWS range was 0 to 8. The mean LOS was 56.8 hours for patients with PEWS 0-1 compared to 62.7 hours for patients with PEWS ≥2 (p=0.02). There was a significant difference in PEWS for LOS ≤24 and ≤36 hours in comparison to those with LOS >24 hours and >36 hours, respectively (p<0.001). Overall, the PEWS correlated with LOS (r=0.11, p=0.002). Age correlated inversely with LOS (r=-0.16, p<0.001), without correlation to PEWS (r=-0.002, p= 0.96).

Conclusions: PEWS correlated weakly with LOS. A statistically significant lower PEWS was observed for patients who had short stays (both ≤24 and ≤36 hours) in comparison to those requiring longer inpatient care. Therefore, the PEWS is a useful tool to predict LOS and aid ED physicians to determine disposition, although further prospective studies in centers with OUs would better characterize its ability to suggest admission to an OU compared to the wards.

Improved bed use with creation of a short-stay unit in a cardiac catheterization recovery room

OBJECTIVE

To solve a capacity problem in a pediatric cardiovascular program, a 5- bed short-stay unit was created in the cardiac catheterization recovery room area within a 6-week timeframe. We describe the problem, solution, and early results in hospital performance and patient outcomes.

METHODS

Data were reviewed for 183 patients who underwent various cardiac catheterization procedures and recovered overnight in the cardiac short-stay unit during the first 4 months of operation. The effect on bed use throughout the cardiac program and impact on the usual recovery room operations were assessed.

RESULTS

The cardiovascular inpatient bed shortage was relieved with the creation of a 5-bed short-stay unit, and no cardiac procedures were canceled because of lack of beds during the study period.

CONCLUSION

There was no negative impact on clinical operations in the catheterization laboratory recovery room, and the short-stay unit was cost-effective. According to the rate of admission after recovery in the short-stay unit (5/183), patient selection was appropriate.

Pediatric observation units in the United States: a systematic review

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.

A reduction in hospitalization, length of stay, and hospital charges for croup with the institution of a pediatric observation unit

OBJECTIVES

The aim of the study was to assess the impact of an observation unit (OU) on hospital resource utilization for patients with croup.

METHODS

A retrospective review with the use of a historical control was performed for 2 years of nondischargeable emergency department (ED) patients with croup.

RESULTS

The total number of ED patients with croup was 694 in the first year and 789 in the second year. Hundred seventy patients were enrolled, 66 in the first year and 104 in the second year (76 admitted to the OU and 33 admitted to the ward). There was a reduction in the ward admission rate from 9.5% to 4.2% (P < .0001) from the first to the second year. The median length of stay for the pre-OU group was 27.2 vs 21.3 hours for the post-OU group (P = .03). The median charge for the pre-OU group was $1685 vs $1327 for the post-OU group (P = .03).

CONCLUSIONS

After the introduction of the OU, hospitalization was reduced, and the overall resource utilization for the care of nondischargeable ED patients with croup was reduced.

The pediatric hybrid observation unit: an analysis of 6477 consecutive patient encounters

OBJECTIVES

Pediatric observation units (OUs) are becoming more common in hospitals throughout the United States, providing physicians with a new disposition option for children who are judged to be too ill for home management. Some OUs function as "hybrid" units, serving both acutely ill and injured observation patients as well as scheduled elective procedure patients. How best to utilize this new resource is not yet defined. We studied the utilization of our pediatric hybrid OU during the first 2 years of operation to determine (1) the spectrum and frequency of diagnoses treated, (2) diagnoses and procedures most (and least) likely to attain discharge successfully within 24 hours, and (3) whether age was associated with inability to be discharged from the OU within 24 hours.

METHODS

The study setting was a 20-bed hybrid OU located in a pediatric tertiary care hospital in Salt Lake City, Utah. The records of all patients admitted during the first 2 years of OU operation, from August 1999 through July 2001, were examined retrospectively.

RESULTS

There were 6477 OU admissions: 4189 (65%) for acutely ill and injured observation patients and 2288 (35%) for scheduled elective procedure patients. For the observation patients, median age was 2.5 years and median length of stay was 15.5 hours. Common admission diagnoses in these patients included enteritis/dehydration (n = 722), orthopedic injuries (n = 362), asthma (n = 327), closed head injury (n = 289), urgent transfusion/infusion (n = 221), bronchiolitis (n = 212), croup (n = 207), abdominal pain (n = 199), cellulitis (n = 177), and nonfebrile seizure (n = 98). Overall, 15% of observation patients required subsequent inpatient admission for >24-hour stay. Observation diagnoses that were most likely to require inpatient admission were hematochezia (60%), viral pneumonia (46%), and bronchiolitis (43%). We demonstrated successful OU discharge rates (>85%) for several diagnoses not commonly reported: neonatal hyperbilirubinemia, aseptic meningitis, and diabetic ketoacidosis in the patient with known diabetes. Among the scheduled elective procedure patients, median age was 5.0 years and median length of stay was 3.0 hours. Only 1% of these patients required subsequent inpatient admission. In both populations, age < or =30 days was associated with increased need for inpatient admission, with a relative risk of 1.9 (95% confidence interval: 1.4-2.6) among the observation patients and 13.9 (95% confidence interval: 3.0-65.0) among scheduled procedure patients.

CONCLUSION

Our pediatric hybrid OU played an important role in the treatment of children who were admitted for observation as a result of acute illness or injury, as well as children who required scheduled procedures. For both patient types, we identified diagnoses that are most and least likely to attain successful discharge within 24 hours. The majority (85%) of observation patients were discharged successfully within 24 hours. Successful discharge rates for diagnoses that are not commonly managed in other pediatric OUs were reported. We identified certain age groups within selected diagnoses that may not have been appropriate for the OU.

Physician satisfaction with a pediatric observation unit administered by pediatric emergency medicine physicians

OBJECTIVES

Observation units (OUs) are widely used to care for adults, but little is published about their use in pediatrics. During the planning stages of our pediatric OU, community primary medical doctors (PMDs) expressed concerns about not admitting and managing their own patients in this unit controlled by pediatric emergency physicians. This study surveyed PMDs to determine their satisfaction with the pediatric OU two and a half years after opening.

METHODS

A satisfaction survey was mailed to pediatricians, family practitioners, and pediatric subspecialists whose patients had been admitted to the study pediatric OU from August 1999 to January 2002. A Likert scale ranging 1 to 4 was used to measure satisfaction in 4 areas. In addition, there were questions regarding the utility of the OU for treatment of common pediatric illnesses.

RESULTS

198 of 248 (80%) surveys were returned. Pediatricians (64%) and family practitioners (23%) were represented most often. Fifty-three percent of PMD respondents had 10 or more patients admitted during the study period. Median satisfaction scores were 4 (most satisfied) in all areas measured. Over 60% of physicians surveyed felt that the OU was useful in the treatment of dehydration, gastroenteritis, reactive airway disease, and bronchiolitis.

CONCLUSIONS

The model of an ED-controlled pediatric observation unit received high satisfaction ratings in all areas by community and subspecialty physicians two and a half years after opening. The initial reservations voiced by community physicians have not resurfaced.

Use of an observation unit by a pediatric emergency department for common pediatric illnesses

OBJECTIVE

To describe the use of a pediatric observation unit (OU), including relapse rates for common pediatric illnesses, and to assess effectiveness of OU utilization.

DESIGN

Retrospective, cohort of all emergency department (ED) visits, OU and inpatient unit (IU) admissions.

SETTING

Tertiary care children's hospital.

PARTICIPANTS

All children evaluated in the ED and subsequently admitted to either the OU or IU over a 2-year period.

MAIN OUTCOME MEASURE

Rates with 95% confidence intervals (CI) for OU use and need for subsequent IU admission from OU, and odds ratios (OR) with 95% CI for use of the OU for specific pediatric disorders.

RESULTS

During 10/1/96-9/30/98, there were 44,459 ED visits, 1798 (4.0%) OU admissions, and 3241 (7.3%) inpatient admissions (IA) from the ED. OU mean length of stay was 15.6 +/- 6.1 hours; mean age was 6 +/- 5.3 years with 31% under 2 years of age. Of the total admissions (IU and OU), diagnoses with high OU utilization were: asthma 274/575, 48%; croup 76/125, 61%; enteritis/dehydration 284/470, 60%; poisonings 82/118, 70%; and seizures 80/204, 39%. The likelihood of an OU admission for these illnesses versus IU (adjusted for subsequent need for IU admission) was: asthma OR 1.3 (1.1, 1.5), P < 0.005; croup OR 2.3 (1.6, 3.3), <0.001; enteritis/ dehydration OR 2.8 (2.1, 3.0), P < 0.001; poisonings OR 3.8 (2.5, 5.7), P < 0.001; and seizures OR 0.8 (0.6, 1.2), P = 0.28. For these diagnoses, OU admissions resulting in IU admission occurred for asthma 45/274, 16.4%; croup 7/76, 9.2%; enteritis/ dehydration 13/284, 4.6%; poisonings 3/82, 3.7%; and seizures 15/80, 18.8%, resulting in an overall need for further hospitalization to the IU for these diagnoses of 83/796, 10.4%, (95% CI 8.3, 12.6).

CONCLUSION

Admissions to the observation unit comprised over one third of all admissions from a pediatric ED. Certain pediatric illnesses appear to be well suited for admission to the observation unit, with low likelihood of the need for subsequent admission to the inpatient unit. Given the current trends in third-party payer reimbursements for short (<24 hours) admissions, observation unit use provides a more attractive alternative to inpatient admission for many pediatric patients.

Pediatric observation medicine

Observing pediatric patients in an OU (whether a pediatric or combined or hybrid unit) has many advantages: better patient care, a decrease in missed diagnoses and acuity, better risk management, decreased malpractice liability, cost effectiveness, increased patient and family satisfaction, and psychosocial benefits. Key principles of observation medicine (purpose, time frame, general patient inclusion and exclusion criteria, administration, CQI, and so forth) are equivalent for pediatric and adult observation patients, but there are important differences. Unique characteristics of pediatric observation patients include specific diagnosis, decreased length of stay, less need for cardiac monitoring, a highly variable admission rate, and a decreased percentage or admission rate to the OU from the ED. Whereas the adult OU is primarily a cardiac-monitoring unit, the pediatric OU is a respiratory and infectious disease unit with a frequent need for an i.v. therapy and hydration. Types of pediatric patients commonly treated in an OU include respiratory illnesses (asthma, croup, bronchiolitis, pneumonia), gastrointestinal disorders (gastroenteritis, abdominal pain), dehydration, infections (fever, cellulitis, lymphangitis, pyelonephritis or UTI), overdoses or poisonings, and seizures.

Emergency department observation unit: can it be funded through reduced inpatient admission?

STUDY OBJECTIVE

We sought to test the assumption that an emergency department observation unit can be funded through the reallocation of resources made available through the unit's impact in reducing inpatient admissions and facilitating bed closures.

METHODS

We conducted our study in a tertiary care center ED with 46,000 visits annually. For a 3-month period, all patients admitted to the hospital through the ED were screened by an emergency physician for suitability for admission to an observation unit. Any patient in the hospital for 3 days or less who did not undergo surgery or other inpatient procedure, and who was admitted through the ED, was considered a candidate for the observation unit.

RESULTS

Of 1,840 admissions, 147 patients met the admission criteria. Only 48 (32.2%) could have been treated in an observation unit, and these patients were not admitted to any single unit in high frequency. The potential savings from inpatient bed closures would only have amounted to 1.68 full-time equivalents-not enough to staff a 4-bed observation unit, which would require 5 full-time equivalents.

CONCLUSION

Because of the diffuse and inconsistent effect such a unit had on inpatient bed use, funding for an ED observation unit at our institution could not be justified on the basis of the closure of inpatient beds and transfer of resources.

Role of the short stay observation ward in accident and emergency departments in the United Kingdom

OBJECTIVE

To define the role of the accident and emergency (A&E) short stay ward by a survey of departments in the United Kingdom and review of published reports.

METHODS

A postal questionnaire with telephone follow up to all major A&E departments with short stay beds.

RESULTS

95 departments were found to have short stay beds. These units received between 19000 and 121000 new patients per year (mean 51000, median 50500) and had access to between two and 20 beds (mean 7.5, median 6). The level of provision varied from one bed per 2440 new attendances to one bed per 27250 new attendances (mean 8380, median 6625). Where data on admission rates were available the departments admitted between 0.1% and 13.3% of their new attendances (mean 2.62%, median 1.9%). Cover was typically provided by an A&E senior house officer with frequent senior ward rounds. While the casemix usually included minor head injuries and alcohol intoxicated patients, there was considerable variation in the cases admitted.

CONCLUSIONS

Short stay provision is highly variable in the United Kingdom. While there are many reports of well run short stay units, consistent evidence of clinical value and cost-effectiveness compared to other methods of care is lacking. Further comparative studies are required to define the role of the A&E short stay ward.

Estimated use of a pediatric emergency department observation unit

STUDY OBJECTIVE

To estimate the use of a pediatric ED observation unit, including the number of anticipated admissions per 10,000 pediatric ED visits per year and the distribution of those admissions by age group, by month, and by time of day.

METHODS

Hospital and ED computer records on all ED patients younger than 18 years who were seen during a 2-year period were abstracted for diagnostic, demographic, and time-flow data. We retrospectively reviewed the charts of patients admitted to the hospital and discharged within 24 hours to determine whether discharge in less than 24 hours could have been anticipated and whether the patient could have been cared for in a pediatric ED observation unit. To refine the estimate, we also reviewed the ICD-9 discharge diagnoses of patients who were not admitted to the hospital but spent more than 6 hours in the pediatric ED.

RESULTS

Of 29,667 pediatric ED visits in a 2-year period, 2,940 (10%) resulted in admission. Of 626 patients discharged in less than 24 hours, only 410 met the anticipation and pediatric ED observation unit level of care criteria. Patients younger than 4 years represented 43% of potential observation unit patients; those aged 16 and 17 years represented 15%. Potential use of an observation unit varied throughout the year. Admission occurred between 3 and 11:59 PM in 60% of the patients. Only 20% of the 176 patients who were not admitted to the hospital but spent more than 6 hours in the pediatric ED were estimated to be candidates for a pediatric ED observation unit.

CONCLUSION

On the basis of these data, approximately 150 patients per 10,000 each year who visit the University of Virginia pediatric ED would be likely to use an observation unit. Staffing and facility use would be seasonally uneven and would be required during the busiest part of the day. Furthermore, even in a pediatric ED large enough to admit 365 pediatric ED observation unit patients each year, random daily variation in demand means that a single bed would be inadequate 25% of the time and empty 37% of the time. Optimal use of even a single-bed pediatric ED observation unit would not occur until pediatric ED census exceeded 30,000 to 40,000 visits annually.