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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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Lim CAE, Bailey J, Oh J, Ibia I, Eiting E, Barnett B, Calderon Y, Cowan E. Comparison of Length of Stay Between Children Admitted to an Observation Versus Inpatient Unit. Pediatr Emerg Care 2024; 40:627-631. [PMID: 38713841 DOI: 10.1097/pec.0000000000003174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/09/2024]
Abstract
OBJECTIVES Many children who require hospitalization are ideal candidates for care in pediatric observation units (POUs) rather than inpatient pediatric units. Differences in outcomes between children cared for in these 2 practice settings have not been thoroughly evaluated. METHODS In this retrospective cohort study, children aged 0 to 18 years admitted to a POU at a community hospital or inpatient unit at a children's hospital were enrolled if they met specific clinical criteria. Information regarding the current illness, medical history, and hospital course was collected. Hospital length of stay (LOS) was analyzed as the primary outcome; secondary outcomes included conversion to inpatient care for the POU group and return to pediatric emergency department within 7 days. Subgroup analysis was conducted on children presenting with respiratory illnesses. Propensity scores were used as a predictor in the final model. RESULTS One hundred eighty-one admissions, 92 to POU and 89 to an inpatient unit, were analyzed. Mean LOS was 24.4 hours (95% confidence interval [CI], 21.7-27.1) for observation and 43.2 hours (95% CI, 37.8-48.6) for inpatient ( P < 0.01). Among the 126 children admitted for respiratory illnesses, the mean LOS was 32.3 hours (95% CI, 26.0-38.6) for observation and 48.1 hours (95% CI, 42.2-54.0) for inpatient ( P < 0.01). Survival analysis demonstrated a 1.61 (95% CI, 1.07-2.42) fold shorter time to discharge among children admitted to observation compared with inpatient ( P = 0.02) and a 1.70 (95% CI, 1.07-2.71) fold shorter time to discharge from observation compared with inpatient for respiratory illnesses ( P = 0.03). Within 7 days of discharge, 2 (2%) patients from the observation group and 1 (1%) from the inpatient group returned to the pediatric emergency department. CONCLUSIONS These findings suggest that POU may provide the means toward efficient care for children in community settings with illnesses requiring brief hospitalizations. Future work including prospective investigations is needed to ascertain the generalizability of these findings.
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Affiliation(s)
| | - Jennifer Bailey
- Department of Pediatrics, University of California at Los Angeles, Los Angeles, CA
| | | | - Imikomobong Ibia
- Department of Emergency Medicine, Harvard Medical School, Boston, MA
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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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Abstract
OBJECTIVE The aim of this study was to evaluate the effect of an observation unit (OU) in an emergency department on reducing unnecessary use of computed tomography (CT) for minor blunt head trauma. METHODS This study was a retrospective before-and-after study of pediatric patients 18 years or younger with minor blunt head trauma. Patients with a Glasgow Coma Scale score of 14 or 15 who presented to the emergency department were included in the analysis. The rates of head CT use in the period before and after the institution of the OU were compared. RESULTS In total, 4706 patients were analyzed (2344 from the period before and 2362 from period after OU institution). The median age of the patients was 3 years, and 64% were male in each period. The rates of CT use were 5.7% (95% confidence interval [CI], 4.8%-6.7%) in the period before and 4.0% (95% CI, 3.3%-4.9%) in the period after OU institution (P = 0.01). The relative risk reduction was 0.70 (95% CI, 0.54-0.91). CONCLUSIONS The rate of CT use decreased by 30% as a result of OU institution. The OU was an effective means of avoiding an unnecessary head CT for pediatric minor head injuries.
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Abstract
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.
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Bustinduy AL, Chis Ster I, Shaw R, Irwin A, Thiagarajan J, Beynon R, Ladhani S, Sharland M. Predictors of fever-related admissions to a paediatric assessment unit, ward and reattendances in a South London emergency department: the CABIN 2 study. Arch Dis Child 2017; 102:22-28. [PMID: 27551062 DOI: 10.1136/archdischild-2016-310494] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 07/22/2016] [Accepted: 08/02/2016] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To explore the risk factors for ward and paediatric assessment unit (PAU) admissions from the emergency department (ED). DESIGN Prospective observational study. SETTING AND PATIENTS Febrile children attending a large tertiary care ED during the winter of 2014-2015. MAIN OUTCOME MEASURES Ward and PAU admissions, National Institute for Health and Care Excellence (NICE) guidelines classification, reattendance to the ED within 28 days and antibiotic use. RESULTS A total of 1097 children attending the children's ED with fever were analysed. Risk factors for PAU admission were tachycardia (RR=1.1, 95% CI (1 to 1.1)), ill-appearance (RR=2.2, 95% CI (1.2 to 4.2)), abnormal chest findings (RR=2.1, 95% CI (1.2 to 4.3)), categorised as NICE amber (RR 1.7 95% CI (1.2 to 2.5)). There was a 30% discordance between NICE categorisation at triage and statistical internal validation. Predictors of ward admission were a systemic (RR=6.9, 95% CI (2.4 to 19.8)) or gastrointestinal illness (RR=3.8, 95% (1.4 to 10.4)) and categorised as NICE Red (RR=5.9, 95% CI (2.2 to 15.3)). Only 51 children had probable bacterial pneumonia (4.6%), 52 children had a proven urinary tract infection (4.2%), with just 2 (0.2%) positive blood cultures out of 485 (44%) children who received an antibiotic. 15% of all children reattended by 28 days and were more likely to have been categorised as Amber and had investigations on initial visit. CONCLUSIONS Risk factors for PAU and ward admissions are different in this setting with high reattendance rates and very low proportion of confirmed/probable serious bacterial infections. Future studies need to focus on reducing avoidable admissions and antibiotic treatment.
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Affiliation(s)
- Amaya L Bustinduy
- Paediatric Infectious Diseases Research Group, Institute of Infection and Immunity, St George's University of London, London, UK
| | - Irina Chis Ster
- Institute of Infection and Immunity, St George's University of London, London, UK
| | - Rebecca Shaw
- Paediatric Infectious Diseases Research Group, Institute of Infection and Immunity, St George's University of London, London, UK.,Children's Emergency Department, St George's NHS trust, London, UK
| | - Adam Irwin
- Paediatric Infectious Diseases Research Group, Institute of Infection and Immunity, St George's University of London, London, UK
| | | | - Rhys Beynon
- Children's Emergency Department, St George's NHS trust, London, UK
| | - Shamez Ladhani
- Paediatric Infectious Diseases Research Group, Institute of Infection and Immunity, St George's University of London, London, UK.,Immunisation Department, Public Health England, London, UK
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, Institute of Infection and Immunity, St George's University of London, London, UK
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Cheng AHY, Barclay NG, Abu-Laban RB. Effect of a Multi-Diagnosis Observation Unit on Emergency Department Length of Stay and Inpatient Admission Rate at Two Canadian Hospitals. J Emerg Med 2016; 51:739-747.e3. [PMID: 27687168 DOI: 10.1016/j.jemermed.2015.12.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 11/26/2015] [Accepted: 12/15/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Observation units (OUs) have been shown to reduce emergency department (ED) lengths of stay (LOS) and admissions. Most published studies have been on OUs managing single complaints. OBJECTIVE Our aim was to determine whether an OU reduces ED LOS and hospital admission rates for adults with a variety of presenting complaints. METHODS We comparatively evaluated two hospitals in British Columbia, Canada (hereafter ED A and ED B) using a pre-post design. Data were extracted from administrative databases. The post-OU cohort included all adults presenting 6 months after OU implementation. The pre-OU cohort included all adults presenting in the same 6-month period 1 year before OU implementation. RESULTS There were 109,625 patient visits during the study period. Of the 56,832 visits during the post-OU period (27,512 to ED A and 29,318 to ED B), 1.9% were managed in the OU in ED A and 1.4% in ED B. Implementation was associated with an increase in the median ED LOS at ED A (179.0 min pre vs. 192.0 min post [+13.0 min]; p < 0.001; mean difference -12.5 min, 95% confidence interval [CI] -15.2 to -9.9 min), but no change at ED B (182.0 min pre vs. 182.0 min post; p = 0.55; mean difference +2.0 min, 95% CI -0.7 to +4.7 min). Implementation significantly decreased the hospital admission rate for ED A (17.8% pre to 17.0% post [-0.8%], 95% CI -0.18% to 0.15%; p < 0.05) and did not significantly change the hospital admission rate at ED B (18.9% pre to 18.3% post [-0.6%], 95% CI -1.19% to -0.09%; p = 0.09). CONCLUSIONS A multi-diagnosis OU can reduce hospital admission rate in a site-specific manner. In contrast to previous studies, we did not find that an OU reduced ED LOS. Further research is needed to determine whether OUs can reduce ED overcrowding.
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Affiliation(s)
- Amy H Y Cheng
- Department of Emergency Medicine, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Neil G Barclay
- Department of Emergency Medicine, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Riyad B Abu-Laban
- Department of Emergency Medicine, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
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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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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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Prospective evaluation of an ED observation unit protocol for trauma activation patients. Am J Emerg Med 2012; 30:1402-6. [DOI: 10.1016/j.ajem.2011.10.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2011] [Revised: 10/03/2011] [Accepted: 10/08/2011] [Indexed: 11/22/2022] Open
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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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Macy ML, Hall M, Shah SS, Harding JP, Del Beccaro MA, Hain PD, Hronek C, Alpern ER. Pediatric observation status: are we overlooking a growing population in children's hospitals? J Hosp Med 2012; 7:530-6. [PMID: 22371384 DOI: 10.1002/jhm.1923] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Revised: 01/19/2012] [Accepted: 01/21/2012] [Indexed: 11/07/2022]
Abstract
BACKGROUND Inpatient administrative datasets often exclude observation stays, as observation is considered to be outpatient care. The extent to which this status is applied to pediatric hospitalizations is not known. OBJECTIVE To characterize trends in observation status code utilization and 1-day stays among children admitted from the emergency department (ED), and to compare patient characteristics and outcomes associated with observation versus inpatient stays. DESIGN Retrospective longitudinal analysis of the 2004-2009 Pediatric Health Information System (PHIS). SETTING Sixteen US freestanding children's hospitals contributing outpatient and inpatient data to PHIS. PATIENTS Admissions to observation or inpatient status following ED care in study hospitals. MEASUREMENTS Proportions of observation and 1-day stays among all admissions from the ED were calculated each year. Top ranking discharge diagnoses and outcomes of observation were determined. Patient characteristics, discharge diagnoses, and return visits were compared for observation and 1-day stays. RESULTS The proportion of short-stays (including both observation and 1-day stays) increased from 37% to 41% between 2004 and 2009. Since 2007, observation stays have outnumbered 1-day stays. In 2009, more than half of admissions from the ED for 6 of the top 10 ranking discharge diagnoses were short-stays. Fewer than 25% of observation stays converted to inpatient status. Return visits and readmissions following observation were no more frequent than following 1-day stays. CONCLUSIONS Children admitted under observation status make up a substantial proportion of acute care hospitalizations. Analyses of inpatient administrative databases that exclude observation stays likely result in an underestimation of hospital resource utilization for children.
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Affiliation(s)
- Michelle L Macy
- Department of Emergency Medicine and the Child Health Evaluation and Research (CHEAR) Unit, Division of General Pediatrics, University of Michigan, Ann Arbor, MI, USA.
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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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Najaf-Zadeh A, Hue V, Bonnel-Mortuaire C, Dubos F, Pruvost I, Martinot A. Effectiveness of multifunction paediatric short-stay units: a French multicentre study. Acta Paediatr 2011; 100:e227-33. [PMID: 21575056 DOI: 10.1111/j.1651-2227.2011.02356.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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High turnover stays for pediatric asthma in the United States: analysis of the 2006 Kids' Inpatient Database. Med Care 2010; 48:827-33. [PMID: 20706158 DOI: 10.1097/mlr.0b013e3181f2595e] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Pediatric observation units provide an alternative to traditional hospitalization. The extent to which observation units could replace inpatient care for asthmatic children is unknown. OBJECTIVE To describe brief inpatient ("high-turnover," HTO) stays for US children hospitalized with a principal discharge diagnosis of asthma, to characterize cases that may be appropriate for observation. DESIGN We analyzed the 2006 Kids' Inpatient Database, a nationally representative sample of hospital discharges. HTO stays were defined as hospitalizations of 0 or 1 night in duration. We conducted descriptive statistics and case-mix adjusted, sample-weighted regression analysis of HTO stays, and associated hospital charges. SUBJECTS Discharges among children aged 2 to 20 years with a principal discharge diagnosis of asthma. MEASURES HTO stays and total charges. RESULTS Overall, 34,592 (34%) pediatric asthma hospitalizations were HTO, accounting for 66,278 hospital days in 2006. HTO stays were associated with younger age, uncomplicated asthma, and private insurance. Freestanding children's hospitals had the highest proportion of HTO stays, 38% (95% CI: 34%-42%) compared with 32% (95% CI: 28%-36%) for children's units and 33% (95% CI: 31%-34%) for general hospitals. In multivariate regression analyses, charges were significantly higher across hospital types when HTO stays begin in the emergency department. CONCLUSIONS The presence of a large number of HTO stays for children hospitalized for asthma suggests the need to explore opportunities to restructure care for this condition, perhaps through the development of physically or operationally distinct observation units.
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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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Madsen T, Dawson M, Bledsoe J, Bossart P. Serial hematocrit testing does not identify major injuries in trauma patients in an observation unit. Am J Emerg Med 2010; 28:472-6. [PMID: 20466228 DOI: 10.1016/j.ajem.2009.01.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2008] [Revised: 01/26/2009] [Accepted: 01/27/2009] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Routine serial hematocrit measurements are a component of the trauma evaluation for patients without serious injury identified on initial evaluation. We sought to determine whether serial hematocrit testing was useful in detecting significant intra-abdominal injuries in trauma patients in our observation unit. METHODS We performed a retrospective chart review of all trauma patients placed in our observation unit over a 14-month period. Patients had received trauma surgery evaluation before placement in the observation unit and routinely received serial hematocrit testing (>or=2 hematocrit levels) while in the observation unit. We compared trauma patients with a hematocrit drop of 5 points or more to those without a significant hematocrit drop. RESULTS Three hundred sixty-five trauma patients were placed in the observation unit, and 310 patients (85%) had at least 2 hematocrits drawn during their stay. Of these patients, 20.6% had a hematocrit drop of 5 or more. Of patients with the hematocrit change, 18.8% were admitted to an inpatient unit from the observation unit compared to 9.3% of patients without a significant hematocrit change (P = .034). In one of these patients who had a computed tomography scan before observation admission, which demonstrated free fluid, the hematocrit drop assisted in diagnosing significant intra-abdominal injury. CONCLUSION Although serial hematocrit testing may be useful in specific situations, routine use of serial hematocrit testing in trauma patients at a level I trauma center's observation unit did not significantly aid in the detection of occult injury.
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Affiliation(s)
- Troy Madsen
- Division of Emergency Medicine, University of Utah, Salt Lake City, UT 84132, USA.
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Appropriately screened geriatric chest pain patients in an observation unit are not admitted at a higher rate than nongeriatric patients. Crit Pathw Cardiol 2009; 7:245-7. [PMID: 19050421 DOI: 10.1097/hpc.0b013e31818efb86] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Observation units may exclude geriatric patients (defined as age >or=65) due to the high rate of observation failure (admission to an inpatient unit) among these patients. We evaluated whether geriatric patients on a chest pain protocol are admitted to an inpatient unit from an emergency department (ED) observation unit at a higher rate than nongeriatric patients. METHODS This was a retrospective chart review of all patients placed in the ED observation unit at the University of Utah Medical Center over a 14-month period from April 2006 to June 2007. The observation unit did not exclude geriatric patients nor did it exclude patients with a history of coronary disease; patients were admitted per the discretion of the attending ED physician. Patient information, including age, date of admission, history of coronary disease (defined as a previous myocardial infarction, stent, or coronary artery bypass graft), and admission to an inpatient unit from the observation unit, was recorded. Decision to admit to an inpatient unit was made by the consulting cardiologist. Results were analyzed using chi2 statistics. RESULTS One hundred thirty-four geriatric patients were admitted to the observation unit under the chest pain protocol during the study period. Seventeen percent of these patients were admitted to an inpatient unit from the observation unit versus 10.7% of the 394 chest pain patients who were under age 65 (P = 0.048). Geriatric patients were more likely to have coronary disease (31.3%) than nongeriatric patients (20.8%; P = 0.013). We then performed a subanalysis on the 404 patients (92 geriatric, 312 nongeriatric) who had no history of coronary disease. Geriatric patients without a history of coronary disease had a 12% inpatient admission rate from the observation unit versus a 7.7% admission rate for nongeriatric patients without a history of coronary disease (P = 0.2). CONCLUSION Geriatric patients without a history of coronary artery disease were admitted to an inpatient unit at a rate consistent with a generally accepted observation failure rate of 10%. When screened appropriately, these patients may be appropriate for chest pain evaluation in the ED observation unit.
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Abstract
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.
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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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Lee JY, Choi UY, Lee SY, Lee JY, Lee BC, Hwang HS, Mok HR, Jeong DC, Chung SY, Kang JH. An analysis of one-year experience of pediatric observation unit: The first report in Korea. KOREAN JOURNAL OF PEDIATRICS 2007. [DOI: 10.3345/kjp.2007.50.7.622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Jee Young Lee
- Department of Pediatrics, College of Medicine The Catholic University of Korea, Korea
| | - Ui-Yoon Choi
- Department of Pediatrics, College of Medicine The Catholic University of Korea, Korea
| | - Soo Young Lee
- Department of Pediatrics, College of Medicine The Catholic University of Korea, Korea
| | - Ji-Young Lee
- Department of Nursing, College of Medicine The Catholic University of Korea, Korea
| | | | - Hui Sung Hwang
- Department of Pediatrics, College of Medicine The Catholic University of Korea, Korea
| | - Hye Rin Mok
- Department of Pediatrics, College of Medicine The Catholic University of Korea, Korea
| | - Dae Chul Jeong
- Department of Pediatrics, College of Medicine The Catholic University of Korea, Korea
| | - Seung Yun Chung
- Department of Pediatrics, College of Medicine The Catholic University of Korea, Korea
| | - Jin Han Kang
- Department of Pediatrics, College of Medicine The Catholic University of Korea, Korea
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