A short stay or 23-hour ward in a general and academic children's hospital: are they effective?

Short stay unit led by pediatric hospital medicine advanced practice providers

BACKGROUND

In response to a critical pediatric bed shortage in 2022, an urgent process change was required to provide safe and timely medical care. We proposed a pilot for an advanced practice provider (APP)-run short stay unit (SSU) for select pediatric hospital medicine (PHM) patients.

OBJECTIVE

To compare length of stay (LOS) and cost before and after implementation of a PHM APP-led SSU pilot at a tertiary pediatric hospital.

DESIGNS, SETTINGS, AND PARTICIPANTS

Single-center prospective pilot observational cohort study with historical control. Observation encounters for patients with asthma, bronchiolitis, croup, and dehydration were included.

INTERVENTION

An independent-practice model SSU staffed by APPs on the PHM service.

MAIN OUTCOME AND MEASURES

SSU encounters (September 1, 2022-December 1, 2022) were compared against pre-SSU encounters (September 1, 2021-August 31, 2022). Cohorts were described with summary statistics. SSU encounters were matched against pre-SSU encounters based on demographics and diagnosis, and the average effect of treatment was calculated. LOS was abstracted from the enterprise data warehouse and standardized unit cost from the Pediatric Health Information Systems database.

RESULTS

There were 1110 encounters included, 155 in the SSU cohort and 955 in the pre-SSU cohort: 24.2% asthma, 30.8% bronchiolitis, 8.3% croup, and 36.7% dehydration. Median (interquartile range) unit LOS decreased from 21 (16-26) to 18 (10-22) h, p < .001. Cost decreased from $3593 ($3031-$4560) to $2958 ($2278-$3856), p < .001. After matching, the average treatment effect was reduction of 3.88 h (95% confidence interval [CI] 1.91-5.85) and $593 (95% CI $348-$839). There were no significant differences in 7-day ED revisit rates.

[Analysis of pediatric «short stays» in a second-level hospital throughout 25 years]

INTRODUCTION

It is essential to admit patients to hospital in an efficient way in order to use resources rationally. Short hospitalary stays are hospitalizations which does not include 00:00h and are considered avoidable. This study describes trends and characteristics of short stays throughout 25 years in our hospital.

PATIENTS AND METHODS

We analyzed hospital pediatric discharges in a second-level hospital through the registration system «conjunto mínimo básico de datos». We categorized pediatric patients and newborn patients in two groups according to length of hospital stay: «short stays» and «prolonged stays». We analyzed and compared the following variables: gender, age, type of admission, month, diagnosis-related groups (DRG) and admission service. Binary logistic regression analysis and assessment of trends through joinpoint regression analysis were performed.

RESULTS

From 1993 to 2017, 45710 children were admitted to our hospital, of which 7.3% were short stays. The trend analysis showed a point of change upwards-downwards at the beginning of the millennium. Pediatric short stays: the most important variables were emergency admissions (89%), urgent transfers (9%), month December (11%) and main diagnosis category: nervous system (18%). Mean diagnosis-related groups cost was 2432±1115€ in short stays group and 2549±1065€ in prolonged stays.

CONCLUSIONS

Short stays and prolonged stays show a falling trend in our hospital. Short stays percentage in our environment is similar to other neighbor countries. Some of our short stays are urgent transfers and admissions for clinical observation. We did not find clinical significance in weight or cost of pediatric patients' DRG comparing to prolonged stays.

Interventions to reduce acute paediatric hospital admissions: a systematic review

BACKGROUND

Admission rates are rising despite no change to burden of illness, and interventions to reduce unscheduled admission to hospital safely may be justified.

OBJECTIVE

To systematically examine admission prevention strategies and report long-term follow-up of admission prevention initiatives.

DATA SOURCES

MEDLINE, Embase, OVID SP, PsychINFO, Science Citation Index Expanded/ISI Web of Science, The Cochrane Library from inception to time of writing. Reference lists were hand searched.

STUDY ELIGIBILITY CRITERIA

Randomised controlled trials and before-and-after studies.

PARTICIPANTS

Individuals aged <18 years.

STUDY APPRAISAL AND SYNTHESIS METHODS

Studies were independently screened by two reviewers with final screening by a third. Data extraction and the Critical Appraisals Skills Programme checklist completion (for risk of bias assessment) were performed by one reviewer and checked by a second.

RESULTS

Twenty-eight studies were included of whom 24 were before-and-after studies and 4 were studies comparing outcomes between non-randomised groups. Interventions included referral pathways, staff reconfiguration, new healthcare facilities and telemedicine. The strongest evidence for admission prevention was seen in asthma-specific referral pathways (n=6) showing 34% (95% CI 28 to 39) reduction, but with evidence of publication bias. Other pathways showed inconsistent results or were insufficient for wider interpretation. Staffing reconfiguration showed reduced admissions in two studies, and shorter length of stay in one. Short stay admission units reduced admissions in three studies.

CONCLUSIONS AND IMPLICATIONS

There is little robust evidence to support interventions aimed at preventing paediatric admissions and further research is needed.

Paediatric attendances of the emergency department in a major Irish tertiary referral centre before and after expansion of free GP care to children under 6: a retrospective observational study

OBJECTIVES

To examine the characteristics of paediatric attendances to the emergency department (ED) in Cork University Hospital (CUH) before and after the expansion of free general practitioner (GP) care to children under the age of 6 years.

DESIGN

This is a retrospective observational study that used a large administrative dataset.

SETTING

The study was conducted in major Irish tertiary referral centre that serves a total population of over 1.1 million. It is a public hospital, owned and managed by the health service executive.

PARTICIPANTS

Children aged 0-15 years who attended CUH ED during the study period of 6 years (2012-2018) were included in this study (n=76 831).

INTERVENTIONS

Free GP care was expanded to all children aged 0-5 years in July 2015.

MAIN OUTCOME MEASURES

Paediatric attendances to CUH ED were examined before (Time Period 1: July 2012-June 2015) and after (Time Period 2: July 2015-June 2018) the expansion of free GP care to children under 6. Changes in GP referral rates and inpatient hospital admissions were investigated.

RESULTS

Paediatric presentations to CUH ED increased from 35 819 during the Time Period 1 to 41 012 during the Time Period 2 (14.5%). The proportion of the CUH ED attendances through GP referrals by children under 6 increased by over 8% in the Time Period 2 (from 10 148 to 14 028). Although the number of all children who attended CUH ED and were admitted to hospital increased in Time Period 2 (from 8704 to 9320); the proportion of children in the 0-5 years group who attended the CUH ED through GP referral and were subsequently admitted to hospital, decreased by over 3%.

CONCLUSION

The expansion of free GP care has upstream health service utilisation implications, such as increased attendances at ED, and should be considered and costed by policy-makers.

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.

System outcomes associated with a pediatric emergency department clinical decision unit

OBJECTIVES

Our objectives were to describe disposition decisions and emergency department return (EDR) rates following a clinical decision unit (CDU) stay; and to determine changes to short stay (&lt;48 hour) hospitalization rates after CDU implementation.

METHODS

We conducted a retrospective cohort study of pediatric emergency department (PED) visits with a CDU stay from January 1 to December 31, 2015. Health records data were extracted onto standardized online forms, then used to determine disposition and 7-day EDR rates. Two trained investigators blindly reviewed EDR visits to determine if they were related to the index CDU stay. We compared short stay inpatient admission rates (i.e., hospital length of stay &lt;48 hours) in 2013 and 2015, before and after CDU implementation.

RESULTS

Of 1696 index CDU stays, 1503 (89%) were discharged, and 139 discharged patients (9.2%) had ≥1 clinically-related EDR. Median (IQR) CDU length of stay (LOS) was 4.4 hours (2.7-7.8) and total PED LOS (including CDU) was 7.8 hours (5.4-12.0). Asthma represented 31% of cases. Short stay hospitalization rate decreased from 3.62% in 2013 to 3.23% in 2015 (difference=0.39%; 95% CI=0.15-0.63; p=0.001).

CONCLUSIONS

Most CDU patients were discharged, but 9% had a clinically-related ED revisit. CDU implementation was associated with a small but significant reduction in short stay hospitalization.

Care of Respiratory Conditions in an Observation Unit

In adults, respiratory disorders are the second most frequent diagnoses treated in emergency department observation units (EDOUs) and account for the most frequent indication for placement of pediatric patients into an EDOU. With appropriate patient selection, chronic obstructive pulmonary disease exacerbations, and community-acquired pneumonia can be managed in the EDOU. EDOU management results in equivalent or better outcomes than inpatient care with decreased length of stay, increased patient satisfaction, lower cost and in some studies decreased mortality. Evidence-based protocols are important to ensure appropriate patients are placed in the EDOU, standardize best practice interventions, and guide disposition decisions.

Alternatives to ward admission from the emergency department

There is ever-increasing pressure on hospital resources in general and emergency departments (ED) in particular. At the same time, there is increasing recognition that traditional inpatient ward-based care is not necessary for the majority of children presenting to the ED with acute illness, and that there are patient, family and hospital benefits to pursuing other options. Here, we describe alternative pathways for children presenting to the ED, including short stay and observational medicine, hospital-in-the-home and non-admission enhanced care, in other words, additional management practices or pathways for children who are discharged from the ED. We discuss the principles, models and practical considerations involved in each of these.

The unannounced patient in the corridor: trust, friction and person-centered care

In this study, a Swedish cancer clinic was studied where three to four unscheduled patients sought support from the hospital on a daily basis for pain and nutrition problems. The clinic was neither staffed nor had a budget to handle such return visits. In order to offer the patients a better service and decrease the workload of the staff in addition to their everyday activities, a multidisciplinary team was established to address the unscheduled return visits. The team was supposed to involve the patient, build trust, decrease the friction, and contribute to a successful rehabilitation process. Data were collected from the patients and the staff. Patients who encountered the team (intervention) and patients who encountered the regular ad hoc type of organization (control) answered a questionnaire measuring trust and friction. Nurses in the control group spent 35% of their full-time employment, and the intervention group staffed with nurses spent 30% of their full-time employment in addressing the needs of these return patients. The patients perceived that trust between them and the staff was high. In summary, it was measured as being 4.48 [standard deviation (SD) = 0.82] in the intervention group and 4.41 (SD = 0.79) in the control group using the 5-point Likert scale. The data indicate that using a multidisciplinary team is a promising way to handle the problems of unannounced visits from patients. Having a team made it cost effective for the clinic and provided a better service than the traditional ad hoc organization. Copyright © 2015 John Wiley & Sons, Ltd.

Unexpected hospitalisations at a 23-hour observation unit in a paediatric emergency department of northern India

BACKGROUND

The 23-hour Observation Unit (OU) is a novel and an effective means for tackling overcrowding in busy Paediatric Emergency Departments (PED) worldwide. However, unexpected hospitalisations in the OU involve transfer of care and they reduce the efficiency of the OU. Hence, we aimed to study the presenting diagnoses which were responsible for the unexpected hospitalisations in a 23-hour OU.

METHODS AND DESIGN

A prospective cohort study Setting: The PED at a tertiary care teaching hospital.

DURATION

15th Feb-15th March 2011.

PROTOCOL

Consecutive children were triaged at presentation to the PED, according to the WHO paediatric emergency triage algorithm. Those who were transferred to the 23-hour OU, were further followed up for duration of the stay, the hospital course, and the outcome (discharge/hospitalisation).

RESULTS

Three hundred (228 males, 72 females) consecutive children who attended the PED over one month were enrolled. All the children, at presentation, were triaged by the medical intern/s who was/were posted in the PED, and they were crosschecked by a PED consultant. A majority (55%, n=165) of the children were triaged as non-urgent, 32% (n=97) as priority and 13% (n=38) as emergent. Out of the 300 children, 173(58%) were transferred to the 23-hour OU. Of these, 16 (9.1%) required unexpected hospitalisations. The children who required hospitalisations had the following diagnoses: bronchiolitis (4), bronchopneumonia (4), seizure (2), viral hepatitis (2), high fever (1), bronchial asthma (1), severe anaemia (1), and urticaria (1). The mean duration of the stay in the OU was 19 hours for those who needed hospitalisation, as against 13 hours for those who were discharged from the OU.

CONCLUSION

The children with respiratory complaints (bronchiolitis and bronchopneumonia) need frequent monitoring in the 23-hour OU, as they have high hospitalisation rates in the OU.

Bronchiolitis: Can objective criteria predict eligibility for brief hospitalization?

OBJECTIVE

To determine if 3 objective criteria - pulse oximetry, respiratory syncytial virus (RSV) testing, and age - could be used to predict which children hospitalized with bronchiolitis will have brief (<36 hour) hospitalizations and therefore be potential candidates for admission to short-stay observation units.

METHODS

This was a retrospective medical record review of medically uncomplicated children 3 to 24 months of age with emergency department and hospital discharge diagnoses consistent with bronchiolitis who were admitted to a general pediatric ward in our university-based, tertiary care hospital between Jan. 1, 1992, and Nov. 12, 2002. Multiple logistic regression was used to assess the predictor variables.

RESULTS

Our study consisted of 225 patients (45% female) with a median age of 7 months (interquartile range [IQR], 4-11 mo; range, 3-22 mo). Median pulse oximetry value was 94% (IQR 91%-96%; range 76%-100%), and 71% of the patients tested positive for RSV. Thirty children (13%) had brief hospitalizations <36 hours, and the median hospital length of stay for the entire study group was 70 hours (IQR 46-108 h; range 6-428 h). None of the 3 predictor variables were independently associated with brief hospitalization.

CONCLUSIONS

Pulse oximetry, RSV testing and age do not predict which children will have brief hospitalizations and are appropriate candidates for admission to short-stay observation units.

Burden of rotavirus hospitalisations in young children in three paediatric hospitals in the United States determined by active surveillance compared to standard indirect methods

AIM

  The number of rotavirus hospitalisations is usually estimated from assigned diagnosis codes for gastroenteritis despite lack of validation for these indirect methods. Reliable estimates before and after introduction of vaccines are needed to quantify the absolute impact of new immunisation programs.

METHODS

  This 2-year study conducted at three hospitals prior to the licensure of the rotavirus vaccines in the USA compared two indirect methods for estimating hospitalisations for rotavirus gastroenteritis with estimates derived from prospective recruitment of children presenting with diarrhoea, vomiting or fever. For active surveillance, rotavirus gastroenteritis was confirmed by demonstration of stool antigen. The indirect residual and proportional methods assumed rotavirus to have caused a proportion of hospitalisations coded as acute gastroenteritis identified from computerised records.

RESULTS

  There were 447 rotavirus hospitalisations among inpatients 31 days through 4 years of age admitted with vomiting and/or diarrhoea, compared with 306 and 228 hospitalisations identified by the two indirect methods. Only 52% of children hospitalised with gastroenteritis received a qualifying diagnosis code at discharge. Relative to active surveillance, the sensitivity and specificity (95% confidence interval (CI)) in identifying rotavirus-attributable hospitalisations was 45% (95% CI: 43-48%) and 89% (88-90%) for the residual method and 34% (30-39%) and 92% (90-94%) for the proportional method.

CONCLUSIONS

  Many children admitted to the hospital with diarrhoea, vomiting or fever were not assigned discharge codes for acute gastroenteritis. Consequently, standard indirect methods missed a substantial number of rotavirus-associated hospitalisations, thereby underestimating the absolute number of children who could potentially benefit from vaccination.

Pediatric observation units

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.

Effectiveness of multifunction paediatric short-stay units: a French multicentre study

AIM

To describe the characteristics of the activities of multifunction paediatric 'short-stay units' (SSU) including observation unit (OU), medical assessment and planning unit (MAPU) and holding unit (HU), to evaluate their effectiveness and to explore predictors of inappropriate admissions for OU patients.

METHODS

Admissions to nine French paediatric SSUs were analysed. The main outcome measures were SSU length of stay with associated outcome for all patients and appropriate admission rate for OU patients.

RESULTS

Of 1084 patients included in the study, 66% were OU patients (n = 718), 21% MAPU patients (n = 225) and 13% HU patients (n = 141). The OU patients constituted the majority of the SSU admissions. The appropriate OU admission rates ranged from 52% to 86%. Head trauma and seizure were the conditions with the highest appropriate OU admission rates (82%). Age <1 year, and need for IV fluids or medications, CT-Scan or MRI and cardiorespiratory monitoring were associated with an increased risk of inappropriate OU admission. Eighteen per cent of the MAPU patients and 5% of the HU patients were discharged home within 24 h.

CONCLUSION

By providing extended and easily available facilities for diagnostics and early treatment for a wide range of sick children, the French paediatric SSU is an effective model for 'observation medicine' in emergency department-managed units. The experience and principles may be applicable to similar units in other health care systems.

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.

O processo de recuperação da criança após a alta hospitalar: revisão integrativa

OBJETIVO: Identificar o conhecimento disponível a respeito do processo de recuperação da criança hospitalizada e de sua família após a alta. MÉTODOS: Revisão integrativa da literatura realizada em bases de dados, de âmbito nacional e internacional, com abordagem qualitativa dos dados. RESULTADOS: Os 16 artigos selecionados pertencem a periódicos internacionais, foram publicados entre 1990 a 2005 e permitiram a identificação dos seguintes temas: Manifestações biopsicossociais da criança e da família. Fatores relacionados às manifestações biopsicossociais da criança e da família; Benefícios da alta precoce da criança e Necessidades de informação e apoio. CONCLUSÕES: As intervenções voltadas à criança e à família devem ser iniciadas ainda na hospitalização, a fim de melhorar sua capacidade de enfrentamento. Há necessidade de aprimorar as pesquisas sobre essa temática nos países em desenvolvimento incluindo a perspectiva da família como unidade.

Predicting need for hospitalization in acute pediatric asthma

OBJECTIVES

To develop and validate predictive models to determine the need for hospitalization in children treated for acute asthma in the emergency department (ED).

METHODS

Prospective cohort study of children aged 2 years and older treated at 2 pediatric EDs for acute asthma. The primary outcome was successful ED discharge, defined as actual discharge from the ED and no readmission for asthma within 7 days, versus need for extended care. Among those defined as requiring extended care, a secondary outcome of inpatient care (>24 hours) or short-stay care (<24 hours) was defined. Logistic regression and recursive partitioning were used to create predictive models based on historical and clinical data from the ED visit. Models were developed with data from 1 ED and validated in the other.

RESULTS

There were 852 subjects in the derivation group and 369 in the validation group. A model including clinical score (Pediatric Asthma Severity Score) and number of albuterol treatments in the ED distinguished successful discharge from need for extended care with an area under the receiver-operator characteristic curve of 0.89 (95% confidence interval [CI], 0.87-0.92) in the derivation group and 0.92 (95% CI, 0.89-0.95) in the validation group. Using a score of 5 or more as a cutoff, the likelihood ratio positive was 5.2 (95% CI, 4.2-6.5), and the likelihood ratio negative was 0.22 (95% CI, 0.17-0.28). Among those predicted to need extended care, a classification tree using number of treatments in the ED, clinical score at end of ED treatment, and initial pulse oximetry correctly classified 63% (95% CI, 56-70) of the derivation group as short stay or inpatient, and 62% (95% CI, 55-68) of the validation group.

CONCLUSIONS

Successful discharge from the ED for children with acute asthma can be predicted accurately using a simple clinical model, potentially improving disposition decisions. However, predicting correct placement of patients requiring extended care is problematic.

Setting up a Paediatric Rapid Access Outpatient Unit: views of general practice teams

Background

Rapid Access Outpatient Units (RAOUs) have been suggested as an alternative to hospital inpatient units for the management of some acutely unwell children. These units can provide ambulatory care, delivered close to home, and may prevent unnecessary hospital admission. There are no qualitative data on the views of primary care practitioners regarding these types of facilities. The aim of the study was to explore the opinions of primary care practitioners regarding a newly established RAOU.

Methods

The RAOU was established locally at a district general hospital when inpatient beds were closed and moved to an inpatient centre, based six miles away at the tertiary teaching hospital.

Qualitative, practice based group interviews with primary care practitioners (general practitioners (GPs), nurse practitioners and practice nurses) on their experiences of the RAOU. The data collection consisted of three practice based interviews with 14 participants. The interviews were recorded and transcribed verbatim. Thematic content analysis was used to evaluate the data.

Results

There was positive feedback regarding ease of telephone access for referral, location, and the value of a service staffed by senior doctors where children could be observed, investigated and discharged quickly. There was confusion regarding the referral criteria for the assessment unit and where to send certain children. A majority of the practitioners felt the utility of the RAOU was restricted by its opening hours. Most participants felt they lacked sufficient information regarding the remit and facilities of the unit and this led to some uneasiness regarding safety and long term sustainability.

Conclusion

Practitioners considered that the RAOU offered a rapid senior opinion, flexible short term observation, quick access to investigations and was more convenient for patients. There were concerns regarding opening hours, safety of patients and lack of information about the unit's facilities. There was confusion about which children should be sent to the unit. This study raises questions regarding policy in regard to the organisation of paediatric services. It highlights that when establishing alternative services to local inpatient units, continual communication and engagement of primary care is essential if the units are to function effectively.

Utilization and unexpected hospitalization rates of a pediatric emergency department 23-hour observation unit

OBJECTIVES

The 23-hour observation units (OUs) may be used to avoid unnecessary hospital admissions. However, unexpected hospitalizations from the 23-hour OUs involve transfer of care and may decrease the efficiency and safety of care of the patient and the unit itself. The primary objective of this study was to determine the predictors of unexpected hospitalization for admissions to a pediatric 23-hour OU.

METHODS

This is an observational prospective cohort study of patients admitted to a pediatric 23-hour OU. Bivariate and multivariate regression analyses identify factors associated with unexpected hospitalization.

RESULTS

There were 4453 patients admitted to the 23-hour OU during the study. The overall rate of unexpected hospitalization was 20.3%; the mean 23-hour OU stay was 15 hours. Age, sex, race/ethnicity, and insurance status were not associated with increased unexpected hospitalization rates. Multivariate regression modeling revealed that unexpected hospitalization was associated with subgroups of resources used (intravenous medications and fluids, cardiorespiratory monitoring, respiratory therapist use, and supplemental oxygen), of subspecialty consultation, and of diagnosis categories (including asthma, adenitis, cellulitis, bronchiolitis, and esophageal foreign body ingestions). Experience of the health care provider involved in the care of the patient was not associated with increased unexpected hospitalization.

CONCLUSIONS

Most of the patients (80%) were successfully discharged from the 23-hour OU. Demographics of the patient and practitioner characteristics did not influence the risk of unexpected hospitalizations; however, certain patient diagnoses, use of resources,and subspecialty consultation did increase the risk of unexpected hospitalization and, therefore, may guide future admission criteria for pediatric 23-hour OU.

Review of a paediatric emergency department observation unit

AIM

To review the function of an emergency department paediatric observation unit.

METHOD

A retrospective observational study reviewing the activity of the observation unit for 12 months

RESULTS

During 12 months, 4446 children were admitted to the observation unit and 76% were discharged home: usually within 8 hours. The average admission rate was 12 children in 24 hours. The commonest causes for children being admitted to the observation unit were respiratory problems and gastroenteritis or dehydration.

CONCLUSION

The emergency paediatric observational unit was used to assess and treat children with a variety of conditions. This enabled many children to be managed in the emergency department rather than being admitted to the paediatric wards.

Children with asthma admitted to a pediatric observation unit

OBJECTIVE

Observation units (OUs) serve patients who require more evaluation or treatment than possible during an emergency department visit and who are anticipated to stay in the hospital for a short defined period. Asthma is a common admission diagnosis in a pediatric OU. Our main objective was to identify clinical factors associated with failure to discharge a child with asthma from our OU within 24 hours.

METHODS

Retrospective chart review at a tertiary care children's hospital. Participants were children 2 years or older with asthma admitted from the emergency department to the OU during August 1999 to August 2001. The OU-discharged group comprised those successfully discharged from the OU within 24 hours. The unplanned inpatient admission group comprised those subsequently admitted from the OU to a traditional inpatient ward or those readmitted to the hospital within 48 hours of OU discharge.

RESULTS

One hundred sixty-one children aged 2 to 20 years (median 4.0; 63% boys) met inclusion criteria; 40 patients (25%) required unplanned inpatient admission. In a multiple logistic regression model, 3 factors were associated with need for unplanned inpatient admission: female sex (adjusted odds ratio, 2.6; 95% confidence interval, 1.1-6.4; P = 0.03), temperature 38.5 degrees C or higher (adjusted odds ratio, 6.1; 95% confidence interval, 1.6-23.5; P < 0.01), and need for supplemental oxygen at the end of emergency department management (adjusted odds ratio, 5; 95% confidence interval, 1.7-15.1; P < 0.01).

CONCLUSIONS

Many children with asthma can be admitted to a pediatric OU and discharged safely within 24 hours. Prospective studies are needed to confirm our findings and to identify other factors predictive of unplanned inpatient admission.

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.

Hospital based alternatives to acute paediatric admission: a systematic review

AIMS

To synthesise published evidence of the impacts of introducing hospital based alternatives to acute paediatric admission.

METHODS

Systematic review of studies of interventions for children with acute medical problems. Main outcome measures were: admission or discharge, unscheduled returns to hospital, satisfaction of parents and general practitioners, effects on health service activity, and costs.

RESULTS

Twenty five studies were included: one randomised controlled trial, 23 observational or cross-sectional studies, and one qualitative study. Many studies were of uncertain quality or were open to significant potential bias. About 40% of children attending acute assessment units in paediatric departments, and over 60% of those attending acute assessment units in A&E departments, do not require inpatient admission. There is little evidence of serious clinical consequences in children discharged from these units, although up to 7% may subsequently return to hospital. There is some evidence that users are satisfied with these services and that they are associated with reductions in inpatient activity levels and certain hospital costs. Evidence about the impact of urgent outpatient clinics is very limited.

CONCLUSIONS

Current evidence supports a view that acute paediatric assessment services are a safe, efficient, and acceptable alternative to inpatient admission, but this evidence is of limited quantity and quality. Further research is required to confirm that this type of service reorganisation does not disadvantage children and their families, particularly where inpatient services are withdrawn from a hospital.

Pediatric observation status beds on an inpatient unit: an integrated care model

OBJECTIVES

Describe the usage of observation status (OS) beds on a pediatric inpatient unit and identify diagnoses likely to be successfully discharged compared to those requiring formal inpatient admission.

METHODS

Retrospective chart review of all patients (0-18 years) transferred to pediatric OS beds from the emergency department (ED) between April 1, 1997 and April 30, 1999. Outcome measures consisted of time interval between ED triage and arrival to an OS bed, total hours in observation, and need for admission or transfer. Using relative risk (RR), we compared admission rates for the 4 most common diagnoses.

RESULTS

We studied 800 transfers to pediatric OS beds. Asthma (27%), gastroenteritis/dehydration (16%), infectious disease (12%), and bronchiolitis (9%) were the 4 most common diagnoses. There were 597 patients (75%) successfully discharged from observation and 174 (22%) required inpatient admission. Seventeen patients (2%) were transferred to a psychiatric facility and 12 patients (1%) were transferred to a tertiary care center for further evaluation and treatment. Compared to gastroenteritis/dehydration, patients with asthma were just as likely to be admitted/transferred (RR 1.05, 95% CI, 0.87-1.27), those with an infectious disease were 1.3 times more likely to be admitted/transferred (RR 1.35, 95% CI, 1.0-1.83), and those with bronchiolitis were 2 times more likely to be admitted/transferred (RR 1.92, 95% CI, 1.34-2.74).

CONCLUSIONS

We describe the usage of OS beds in a community hospital that we believe can be a successful model for the care of pediatric patients. Future studies are needed to delineate the clinical characteristics of patients that would benefit from this care delivery model.

[Effectiveness of a short-stay observation unit in a pediatric emergency department]

Short-Stay Observation Units (SSOUs) in paediatric emergency departments are effective in reducing inpatient admissions but can also generate excessive short-stay hospitalisations. The aim of the study was to evaluate both these consequences and the different missions of SSOUs.

METHODS

This prospective study included all children admitted in a 10-bed-medico-surgical SSOU of a tertiary-care paediatric emergency department from September 4, to October 31, 2001. At the time of SSOU admission, the physician indicated the purpose of the admission and which decision he would have made in the absence of a SSOU.

RESULTS

Five hundred and nine children (median age = 4 years, chronic disease: 26%, trauma: 34%) were included, accounting for 15% of admissions. The mean length of stay was 14 +/- 8h. The decision in the absence of a SSOU would have been: inpatient hospitalization (77%), transfer to another hospital in the absence of inpatient room vacancy (7%), discharge home (10%), prolonged waiting in the emergency ward (4%), do not know or not indicated (2%). The SSOU admission was deemed appropriate in 81%: discharge home within 24h was likely in 65% and the final orientation of the child was uncertain in 16%. The admission was debatable in 13% and inappropriate in 6%. Sixty six per cent of children were discharged home.

CONCLUSION

The SSOU reduced inpatient hospitalisations, generated few inappropriate short stay hospitalisations, and seemed particularly efficient for paediatric diseases. Proposed indicators should allow inter-hospital comparisons.

Quadrennial review of a paediatric emergency assessment unit

The primary aim of this article is to report on one aspect of a quadrennial study designed to explore the appropriateness and impact of the development of a paediatric emergency assessment unit (PEAU) as a response to increases in paediatric emergencies presenting to a south-western regional child health unit. In particular, this article will present the findings of a prospective audit of admissions to the PEAU over a 1-month period during the latter part of 2002. The primary method of data collection utilized a structured survey instrument developed using a design and automatic data computer software package, completed by the nursing staff. Anonymized descriptive data were obtained from 223 children admitted to the PEAU during one calendar moth and authorized by the appropriate clinical directorate audit committee as part of its ongoing commitment to the full implementation of clinical governance. The data presented primarily relate to children admitted during the official opening times of the PEAU, and those presenting out of hours. The data analysis demonstrates a reduction in the number of children staying overnight in hospital since the opening of the PEAU, with the majority of children being referred by their own family doctor. Only one child in the sample was readmitted to the PEAU within 24 hours, and two within 24 hours of discharge as inpatients. Although thought to be pertinent, only one child admitted after official closing of the PEAU and out of hours was described as being admitted for social reasons. The International Classification of Diagnosis (ICD) 10 (World Health Organization (WHO), 1994) classifications of the children admitted to the PEAU reflect those found in other similar studies. Overall, the results of this investigation demonstrate that a PEAU can offer an efficient service to GPs, families and others as a route of referral, thus mitigating unnecessary overnight stays for individual children.

Is care in alternative settings safe for infants with possible serious bacterial infection?

Febrile infants are frequently hospitalized for possible serious bacterial illness (SBI). Potential to replace hospitalization of selected febrile infants with care in alternative settings was assessed by estimating risk for deterioration and by determining resource use. Lower and upper bound estimates for the number of infants admitted to a tertiary care hospital from 1994 to 1998 for possible SBI were 537 and 836, respectively. Detailed record reviews were conducted for febrile infants among this group, who, on the basis of positive blood or cerebrospinal cultures, were considered most likely to have SBI. No infant with a positive blood culture who was eligible for alternative setting care (ASC) deteriorated. Ninety-five percent confidence interval for the worst-case (assuming denominator of 537) estimate of risk for deterioration was 0% to 0.56%. Most resource use was compatible with ASC. Alternative setting care for selected febrile infants is both safe and feasible.