Barriers to discharge from a 24-hour observation unit for children with bronchiolitis

Comparison of Length of Stay Between Children Admitted to an Observation Versus Inpatient Unit

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.

Home Care for Bronchiolitis: A Systematic Review

CONTEXT

Bronchiolitis is the leading cause of pediatric hospital admissions. Hospital-at-Home (HAH) delivers hospital-level care at home, relieving pressure on the hospital system.

OBJECTIVES

We aimed to review the feasibility, acceptability, and safety of HAH for bronchiolitis, and assess the cost-impact to hospitals and society.

DATA SOURCES

Ovid Medline, Embase, Pubmed, Cochrane Library, CINAHL, and Web of Science.

STUDY SELECTION

Studies (randomized control trials, retrospective audits, prospective observational trials) of infants with bronchiolitis receiving HAH (oxygen, nasogastric feeding, remote monitoring). Studies were limited to English language since 2000.

DATA EXTRACTION

We reviewed all studies in duplicate for inclusion, data extraction, and risk of bias.

RESULTS

Ten studies met inclusion criteria, all for home oxygen therapy (HOT). One abstract on nasogastric feeding did not meet full inclusion criteria. No studies on remote monitoring were found. HOT appears feasible in terms of uptake (70%-82%) and successful completion, both at altitude and sea-level. Caregiver acceptability was reported in 2 qualitative studies. There were 7 reported adverse events (0.6%) with 0 mortality in 1257 patients. Cost studies showed evidence of savings, although included costs to hospitals only.

LIMITATIONS

Small number of studies with heterogenous study design and quality. No adequately powered randomized control studies.

CONCLUSIONS

Evidence exists to support HOT as feasible, acceptable, and safe. Evidence of cost-effectiveness remains limited. Further research is needed to understand the relevant impact of HAH versus alternative interventions to reduce oxygen prescribing. Other models of care looking at nasogastric feeding support and remote monitoring should be explored.

Home oxygen therapy criteria, guidelines and protocols for hypoxia management in pediatric patients with acute bronchiolitis: a scoping review protocol

REVIEW OBJECTIVE/QUESTION

The objectives of this scoping review are: to explore existing literature related to discharge criteria, guidelines and protocols from hospitals or clinics that are being implemented for home oxygen therapy (HOT) in the management of hypoxia in pediatric patients with acute bronchiolitis, examine and conceptually map the evidence, and identify any gaps in the literature.The question of this review is: what discharge criteria, guidelines, and protocols are used for HOT in the management of hypoxia in pediatric patients with acute bronchiolitis?

Safely Discharging Infants with Bronchiolitis from an Emergency Department: A Five Step Guide for Pediatricians

Recent publications have established the pulse oxygen saturation (SpO₂) threshold of 90% for the hospitalization and discharge of infant patients with bronchiolitis. However, there is no clear recommendation regarding the Emergency Department (ED) observation period necessary before allowing safe home discharge for patients with SpO₂ above 90%-92%. Our primary aims were to evaluate the risk factors associated with delayed desaturation in infants with SpO₂ ≥ 92% on arrival at the ED as well as the ED observation period necessary before allowing safe home discharge. A secondary aim was to identify the risk factors for ED readmission. Of 581 episodes of bronchiolitis in patients < 1 year old admitted to the ED, only 47 (8%) had SpO₂ < 92% on arrival there, although 106 (18%) exhibited a delayed desaturation (to < 92%) during ED observation. Female sex, age < 3 months old, ED readmission, more severe initial clinical presentation, and higher pCO₂ level (> 6KPa) were risk factors for delayed desaturation with OR varying from 1.7 to 7.5. In patients < 3 months old, mean desaturation occured later than in older patients [6.0 hours (IQR 3.0–14.0) vs. 3.0 hours (IQR 2.0–6.0), P = 0.0018]. In 95% of patients with a delayed desaturation this decrease occurred within 25 hours for patients < 3 months old and within 11 hours for patients ≥ 3 months old. In patients < 3 months old with respiratory rates above the normal range for their age the desaturation occurred earlier than in patients < 3 months with normal respiratory rates [4.4 hours (IQR 3.0–11.7) vs. 14.6 hours (IQR 7.6–22.2), P = 0.037]. Based on the present study’s results, we propose a five step guide for pediatricians on discharging children with bronchiolitis from the ED. By using the threshold of an 11 hour ED observation period for patients ≥ 3 months old and a 25 hour period for patients < 3 months old we are able to detect 95% of the patients with bronchiolitis who are at risk of delayed desaturation.

Structure and Function of Observation Units in Children's Hospitals: A Mixed-Methods Study

OBJECTIVE

Observation unit (OU) use has been promoted recently to decrease resource utilization and costs for select patients, but little is known about the operations of pediatric OUs. This study aimed to characterize the infrastructure and function of OUs within freestanding children's hospitals and to compare characteristics between hospitals with and without OUs.

METHODS

All 43 freestanding children's hospitals that submit data to the Pediatric Health Information System were contacted in 2013 to identify OUs that admitted unscheduled patients from their emergency department (ED) in 2011. Semistructured interviews were conducted with representatives at hospitals with these OUs. Characteristics of hospitals with and without OUs were compared.

RESULTS

Fourteen (33%) of 43 hospitals had an OU during 2011. Hospitals with OUs had more beds and more annual ED visits compared to those without OUs. Most OUs (65%) were located in the ED and had <12 beds (65%). Staffing models and patient populations differed between OUs. Nearly 60% were hybrid OUs, providing scheduled services. OUs lacked uniform outcome measures. Themes included: admissions were intuition based, certain patients were not well suited for OUs, OUs had rapid-turnover cultures, and the designation of observation status was arbitrary. Challenges included patient discontent with copayments and payer-driven utilization reviews.

CONCLUSIONS

OUs were located in higher volume hospitals and varied by location, size, and staffing. Most functioned as hybrid OUs. OUs based admissions on intuition, had staffing cultures centered on rapid turnover of patient care, lacked consistent outcome measures, and faced challenges regarding utilization review and patient copayments.

A systematic review of predictive modeling for bronchiolitis

PURPOSE

Bronchiolitis is the most common cause of illness leading to hospitalization in young children. At present, many bronchiolitis management decisions are made subjectively, leading to significant practice variation among hospitals and physicians caring for children with bronchiolitis. To standardize care for bronchiolitis, researchers have proposed various models to predict the disease course to help determine a proper management plan. This paper reviews the existing state of the art of predictive modeling for bronchiolitis. Predictive modeling for respiratory syncytial virus (RSV) infection is covered whenever appropriate, as RSV accounts for about 70% of bronchiolitis cases.

METHODS

A systematic review was conducted through a PubMed search up to April 25, 2014. The literature on predictive modeling for bronchiolitis was retrieved using a comprehensive search query, which was developed through an iterative process. Search results were limited to human subjects, the English language, and children (birth to 18 years).

RESULTS

The literature search returned 2312 references in total. After manual review, 168 of these references were determined to be relevant and are discussed in this paper. We identify several limitations and open problems in predictive modeling for bronchiolitis, and provide some preliminary thoughts on how to address them, with the hope to stimulate future research in this domain.

CONCLUSIONS

Many problems remain open in predictive modeling for bronchiolitis. Future studies will need to address them to achieve optimal predictive models.

Outpatient course and complications associated with home oxygen therapy for mild bronchiolitis

BACKGROUND

Home oxygen has been incorporated into the emergency department management of bronchiolitis in high-altitude settings. However, the outpatient course on oxygen therapy and factors associated with subsequent admission have not been fully defined.

METHODS

We conducted a retrospective cohort study in consecutive patients discharged on home oxygen from the pediatric emergency department at Denver Health Medical Center from 2003 to 2009. The integration of inpatient and outpatient care at our study institution allowed comprehensive assessment of follow-up rates, outpatient visits, time on oxygen, and subsequent admission. Admitted and nonadmitted patients were compared by using a χ(2) test and multivariable logistic regression.

RESULTS

We identified 234 unique visits with adequate follow-up for inclusion. The median age was 10 months (interquartile range [IQR]: 7-14 months). Eighty-three percent of patients were followed up within 24 hours and 94% within 48 hours. The median length of oxygen use was 6 days (IQR: 4-9 days), and the median number of associated encounters was 3 (range: 0-9; IQR: 2-3). Ninety-three percent of patients were on room air at 14 days. Twenty-two patients (9.4%) required subsequent admission. Fever at the initial visit (>38.0°C) was associated with admission (P < .02) but had a positive predictive value of 15.4%. Age, prematurity, respiratory rate, oxygen saturation, and history of previous bronchiolitis or wheeze were not associated with admission.

CONCLUSIONS

There is a significant outpatient burden associated with home oxygen use. Although fever was associated with admission, we were unable to identify predictors that could modify current protocols.

Home oxygen therapy for infants and young children with acute bronchiolitis and other lower respiratory tract infections: the HiTHOx program

BACKGROUND

Acute lower respiratory tract infection (LRTI) including bronchiolitis, is one of the leading causes of pediatric hospital admissions worldwide. Recent studies have demonstrated that some children with acute bronchiolitis can be successfully managed using home oxygen therapy.

AIM

To report the impact of a Hospital in The Home Oxygen therapy program (HiTHOx) for selected infants and young children with acute bronchiolitis and other LRTI.

FINDINGS

The HiTHOx program appears to be a safe model of care for carefully selected infants and young children with acute bronchiolitis and LRTI that reduces the hospital length of stay.

CONCLUSIONS

The HiTHOx program provides an alternative model of care for infants and young children with acute LRTI. Implementation of models of care similar to that of the HiTHOx program in other pediatric health services may have the potential to create additional bed capacity, at the time of year when it is most needed.

Factors associated with prolonged stay in a pediatric emergency observation unit of an urban tertiary children's hospital in China

OBJECTIVES

This study aimed to examine the factors associated with increased length of stay (LOS > 24 hours) in the pediatric emergency observation unit (OU) of an urban tertiary children's hospital in China.

METHODS

This study was a retrospective cohort study. We retrieved and examined all the records of patients (age, 0-16 years) who were admitted to the OU (n = 10,852) during July 1, 2008, to June 30, 2009. The primary outcome was LOS and prolonged stay (LOS > 24 hours). We also performed a sensitivity analysis by using LOS of 3 days or greater and LOS of 6 days or greater as dependent variables in logistic regression and compared with LOS of greater than 24 hours regression to examine the robustness of the associations.

RESULTS

The overall mean (SD) LOS was 24.0 (24.4) hours; 31.3% had LOS of greater than 24 hours, of which the mean (SD) LOS was 50.2 (28.6) hours. The following factors were associated with LOS of greater than 24 hours: age, 28 days to 3 months (odds ratio, [OR], 1.87; 95% confidence interval, 1.36-2.59) and older than 3 months to 12 months (OR, 1.83; 95% CI, 1.35-2.50) compared with age 0 to 28 days; neurologic diseases (OR, 1.50; 95% CI, 1.31-1.72), infectious diseases (OR, 2.00; 95% CI, 1.61-2.49), and visits for non-respiratory-related signs and symptoms (OR, 2.00; 95% CI, 1.61-2.49); acuity level of emergent (OR, 1.79; 95% CI, 1.57-2.04); procedures (OR, 7.09; 95% CI, 4.16-12.10); emergency transfusions (OR, 1.33; 95% CI, 1.01-1.75); staffed by residents (OR, 1.12; 95% CI, 1.01-1.24); and patients living in low-annual gross domestic product districts (OR, 1.14; 95% CI, 1.01-1.29). Arrival at evening (OR, 0.54; 95% CI, 0.49-0.60) and overnight (OR, 0.43; 95% CI, 0.38-0.49) were less likely to have LOS of greater than 24 hours than arrival during day shifts.

CONCLUSIONS

We identified some risk factors for prolonged stay in an OU. These factors are the starting points in understanding issues related to prolonged stay and are needed to assess efficiency and quality of care in pediatric emergency department and OU. Our results have provided information basis for making improvements in the system and may be important considerations for similar institutions, which encounter similar challenges.

Impact of home oxygen therapy on hospital stay for infants with acute bronchiolitis

Acute bronchiolitis has been associated with an increasing hospitalization rate over the past decades. The aim of this paper was to estimate the impact of home oxygen therapy (HOT) on hospital stay for infants with acute bronchiolitis. A retrospective cohort study was done including all children aged ≤ 12 months discharged from a pediatric tertiary-care center with a diagnosis of bronchiolitis, between November 2007 and March 2008. Oxygen was administered according to a standardized protocol. We assumed children with the following criteria could have been sent home with O(2), instead of being kept in hospital: age ≥ 2 months, distance between home and hospital <50 km, in-hospital observation ≥ 24 h, O(2) requirement ≤ 1.0 L/min, stable clinical condition, no enteral tube feeding, and intravenous fluids <50 mL/kg/day. Children with significant underlying disease were excluded. A total of 177 children were included. Median age was 2.0 months (range 0-11), and median length of stay was 3.0 days (range 0-18). Forty-eight percent of patients (85/177) received oxygen during their hospital stay. Criteria for discharge with HOT were met in 7.1 % of patients, a mean of 1.8 days (SD 1.8) prior to real discharge. The number of patient-days of hospitalization which would have been saved had HOT been available was 21, representing 3.0 % of total patient-days of hospitalization for bronchiolitis over the study period (21/701).

CONCLUSIONS

In this study setting, few children were eligible for an early discharge with HOT. Home oxygen therapy would not significantly decrease the overall burden of hospitalization for bronchiolitis.

Risk factors for admission in children with bronchiolitis from pediatric emergency department observation unit

BACKGROUND

Patients with bronchiolitis are increasingly being admitted to emergency department observation units (EDOUs) but often require subsequent hospitalization. To better identify ED patients who should be directly admitted to the hospital rather than the EDOU, the predictors of admission must be identified.

OBJECTIVES

The objective of this study was to determine the predictors of subsequent hospital admission from the EDOU in infants and young children with bronchiolitis.

METHOD

This was a retrospective cohort study of patients younger than 2 years admitted to an EDOU with bronchiolitis between April 1, 2003, and March 31, 2007. Univariate analysis was followed by logistic regression to identify the significant predictors of hospital admission from the EDOU.

RESULTS

There were 325 patients in the study: 67% were younger than 6 months, and 60% were male. Eighty-five (26%) were admitted to the hospital from the EDOU. Predictors for admission from the EDOU included parental report of poor feeding or increased work of breathing, oxygen saturation less than 93%, or ED treatment with racemic epinephrine (Vaponephrine) and intravenous fluids (IVFs).

CONCLUSION

Patients with a history of increased work of breathing or oxygen saturation less than 93% and ED treatment with IVFs are at high risk for admission from the EDOU to the hospital. Direct admission to the hospital from the ED should be considered for these patients, particularly patients treated with IVFs and having an oxygen saturation less than 93% in the ED.

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.

Outpatient management of patients with bronchiolitis discharged home on oxygen: a survey of general pediatricians

OBJECTIVE

To describe the experience of general pediatricians in weaning bronchiolitis patients, treated as outpatients, from oxygen.

METHODS

The authors surveyed members of the American Academy of Pediatrics' Council on Community Pediatrics regarding management of outpatient oxygen for bronchiolitis.

RESULTS

The survey had 214 (28.4%) responses from pediatricians, of whom 172 (80.3%) practiced outpatient pediatrics. Among those, 27 (15.7%) cared for bronchiolitis patients discharged on oxygen. Pediatricians managing home oxygen practiced at higher altitude (5000 vs 339 ft, P < .001). No clear weaning protocol was reported. Over half (61.5%) of the pediatricians managing home oxygen acknowledged difficulty in deciding when to stop oxygen. A median of 2 (interquartile range [IQR] = 2-2) outpatient visits and 6 (IQR = 4-7) outpatient days on home oxygen were needed prior to oxygen discontinuation.

CONCLUSION

Pediatricians are not routinely managing home oxygen for hypoxic bronchiolitis patients. Variable weaning process, difficulties in determining oxygen stoppage, multiple follow-up visits, and prolonged home oxygen usage highlight the need to evaluate the impact of this emerging practice.

Discharged on supplemental oxygen from an emergency department in patients with bronchiolitis

BACKGROUND AND OBJECTIVE

Bronchiolitis is the most common reason for hospital admission in patients aged <1 year. Admissions have been increasing with hypoxia frequently cited as the determinant. Home oxygen (O(2)) has been shown to be feasible, although safety data are lacking. The objective of this study was to evaluate the impact of a home O(2) clinical care protocol on admission rates in patients with bronchiolitis from the pediatric emergency department.

METHODS

We performed a retrospective chart review of patients with bronchiolitis who presented to a children's hospital pediatric emergency department (altitude 1600 m) between 2005 and 2009. Patients between the ages of 1 and 18 months were included in the analysis. Patients requiring baseline O(2) were excluded. We calculated the percentage of patients discharged on O(2) and their readmission rates. We reviewed charts of patients who were admitted after home O(2) for adverse outcomes. We also compared rates of admission before and after initiation of the protocol.

RESULTS

In this study, 4194 illnesses were analyzed; 2383 (57%) were discharged on room air, 649 (15%) were discharged on O(2), and 1162 (28%) were admitted. Of those discharged on room air, 4% were subsequently admitted, and 6% of those discharged on O(2) were admitted. There were no ICU admissions or need for advanced airway management in those patients discharged on O(2). Our overall admission rates for bronchiolitis dropped from a rate of 40% to 31%.

CONCLUSIONS

Home O(2) is an effective way to decrease hospital admissions in a select group of patients with bronchiolitis.