Pediatric observation units

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.

Using Quality Improvement Methodology to Increase Communication of Discharge Criteria on Rounds

OBJECTIVE

Clear communication about discharge criteria with families and the interprofessional team is essential for efficient transitions of care. Our aim was to increase the percentage of pediatric hospital medicine patient- and family-centered rounds (PFCR) that included discharge criteria discussion from a baseline mean of 32% to 75% over 1 year.

METHODS

We used the Model for Improvement to conduct a quality improvement initiative at a tertiary pediatric academic medical center. Interventions tested included (1) rationale sharing, (2) PFCR checklist modification, (3) electronic discharge SmartForms, (4) data audit and feedback and (5) discharge criteria standardization. The outcome measure was the percentage of observed PFCR with discharge criteria discussed. Process measure was the percentage of PHM patients with criteria documented. Balancing measures were rounds length, length of stay, and readmission rates. Statistical process control charts assessed the impact of interventions.

RESULTS

We observed 700 PFCR (68 baseline PFCR from July to August 2019 and 632 intervention period PFCR from November 2019 to June 2021). At baseline, discharge was discussed during 32% of PFCR. After rationale sharing, checklist modification, and criteria standardization, this increased to 90%, indicating special cause variation. The improvement has been sustained for 10 months.At baseline, there was no centralized location to document discharge criteria. After development of the SmartForm, 21% of patients had criteria documented. After criteria standardization for common diagnoses, this increased to 71%. Rounds length, length of stay, and readmission rates remained unchanged.

CONCLUSION

Using quality improvement methodology, we successfully increased verbal discussions of discharge criteria during PFCR without prolonging rounds length.

Admissions and Emergency Visits by Late Preterm Singletons and Twins in the First 5 Years: A Population-Based Cohort Study

OBJECTIVE

To compare admission and emergency visits of late preterm (34^0/7-36^6/7 weeks) versus term infants (37^0/7-41^6/7 weeks) in the first 5 years.

STUDY DESIGN

This population-based cohort study included all singletons and twins born alive at 34^0/7 to 41^6/7 weeks' gestation registered in a health administrative database in Ontario, Canada, between April 1, 2002 and December 31, 2012. Admissions and emergency visits from initial postnatal discharge to 5 years were compared between late preterm and term infants adjusting for maternal and infant characteristics.

RESULTS

A total of 1,316,931 infants (75,364 late preterm infants) were included. Late preterm infants had more frequent admissions than term infants in the first 5 years in both singletons (adjusted incidence rate ratio [95% confidence interval] = 1.46 [1.42-1.49]) and twins (1.21 [1.11-1.31]). The difference in admissions between late preterm and term infants were smaller in twins than singletons and decreased with children's ages. Twins had less frequent admissions than singletons for late preterm infants, but not for term infants. The emergency visits were more frequent in late preterm than term infants in all the periods.

CONCLUSION

Admissions and emergency visits were more frequent in late preterm than term infants through the first 5 years. Admissions were less frequent in late preterm twins than singletons.

Utility of a pediatric observation unit for the management of children admitted to the emergency department

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.

The Effect of an Observation Unit on Pediatric Minor Head Injury

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.

Protocolized emergency department observation care improves quality of ischemic stroke care in Haiti

INTRODUCTION

In many low-income countries, Emergency Medicine is underdeveloped and faces many operational challenges including emergency department (ED) overcrowding and prolonged patient length of stays (LOS). In high-resource settings, protocolized ED observation unit (EDOU) care reduces LOS while preserving care quality. EDOUs are untested in low-income countries. We evaluate the effect protocolized EDOU care for ischemic stroke on the quality and efficiency of care in Haiti.

METHODS

We performed a prospective cohort study of protocolized observation care for ischemic stroke at a Haitian academic hospital between January 2014 and September 2015. We compared patients cared for in the EDOU using the ischemic stroke protocol (study group) to eligible patients cared for before protocol implementation (baseline group), as well as to eligible patients treated after protocol introduction but managed without the EDOU protocol (contemporary reference group). We analysed three quality of care measures: aspirin administration, physical therapy consultation, and swallow evaluation. We also analysed ED and hospital LOS as measures of efficiency.

RESULTS

Patients receiving protocolized EDOU care achieved higher care quality compared to the baseline group, with higher rates of aspirin administration (91% v. 17%, p < 0.001), physical therapy consultation (50% v. 9.6%, p < 0.001), and swallow evaluation (36% v. 3.7%, p < 0.001). We observed similar improvements in the study group compared to the contemporary reference group. Most patients (92%) were managed entirely in the ED or EDOU. LOS for non-admitted patients was longer in the study group than the baseline group (28 v. 19 h, p = 0.023).

CONCLUSION

Protocolized EDOU care for patients with ischemic stroke in Haiti improved performance on key quality measures but increased LOS, likely due to more interventions. Future studies should examine the aspects of EDOU care are most effective at promoting higher care quality, and if similar results are achievable in patients with other conditions.

Evaluation of an Innovative Model of Care for a Limited-Stay Pediatric Unit

Information about pediatric observation and limited-stay unit design and function is lacking in the literature. A quality improvement approach was used to create new care processes on an inpatient unit within a large children's hospital. Outcomes included the use of advanced practice nurse patient care management, creation of 30 clinical pathways to model care, and consistent and faster transfer from emergency department to inpatient unit, resulting in high-level parent and patient satisfaction and decreased nursing turnover.

Development of a combined paediatric emergency department and observation unit

Background

Recent trends towards more cost-efficient and patient-centred treatment are converging to provide opportunities to improve the care of children. Observation units are hospital areas dedicated to the ongoing evaluation and management of patients for a brief period of time for well-defined conditions. We describe the implementation of a paediatric observation unit (POU) adjacent to a paediatric emergency department (PED) in an urban, academic, community hospital.

Methods

Staffing models were designed to provide paediatric services to patients in both the PED and POU. Admission criteria, workflow and transfer guidelines were developed. Quality improvement initiatives were undertaken and evaluated. Unit throughput, patient outcomes and patient satisfaction data were collected and analysed.

Results

Over a 2-year period, there were 24 038 patient visits to the PED. Of these, 1215 (5.1%) patients required admission. Seven hundred and seventy-seven (64.0%) of these children were admitted to the POU. One hundred and nineteen (15.3%) of these patients were subsequently converted to inpatient hospitalisation. The average length of stay (LOS) was 25.7 hours in 2017 and 26.5 hours in 2018. Ten patients returned to the PED within 72 hours of discharge from the POU and four were readmitted. Patient satisfaction scores regarding ‘likelihood to recommend’ improved from the 36th to the 92nd percentile rank over a 1-year period. Close monitoring of patient outcomes allowed for the adjustment of admission guidelines, increased unit census and optimised utilisation.

Conclusion

A combined PED-POU has been successful at our institution in meeting benchmark goals set for LOS and conversion rates. In addition, quality improvement interventions increased patient census and improved patient satisfaction scores while reducing the inpatient burden on the referring children’s hospital.

Managing Skin and Soft Tissue Infections in the Emergency Department Observation Unit

BACKGROUND

Skin and soft tissue infections (SSTIs) are a common reason for presentation to the emergency department (ED) and account for 3% of ED visits. Patients with a diagnosis of cellulitis requiring intravenous (IV) antibiotics have traditionally been admitted to the hospital. In our institution, these patients are placed in the ED Observation Unit (EDOU) for IV antibiotics.

OBJECTIVES

The purpose of this study is to determine if 3 doses of IV antibiotics are adequate to document clinical improvement in children with uncomplicated SSTI.

METHODS

A prospective cohort study of children aged 3 months to 18 years with uncomplicated SSTI admitted (2009-2013) to the EDOU at a children's hospital for IV antibiotics was conducted.

RESULTS

One hundred six patients (mean age, 68 months) were enrolled; 57% were boys, 53% of patients had cellulitis only and 47% had cellulitis with drained abscesses. There was a significant decrease in pain scores and size of cellulitis from arrival to discharge (P < 0.001 and P < 0.001, respectively). Eighty-three percent of patients were discharged after 3 to 4 doses of antibiotics, and 17% were admitted. The location of the wound, presence of systemic symptoms, and prior use of oral antibiotics did not predict admission in our study.

CONCLUSIONS

The EDOU is a reasonable alternative to inpatient admission in the management of patients with uncomplicated SSTI requiring IV antibiotics.

Pediatric emergency room activities in Italy: a national survey

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.

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.

Observation-status patients in children's hospitals with and without dedicated observation units in 2011

BACKGROUND

Pediatric observation units (OUs) have demonstrated reductions in lengths of stay (LOS) and costs of care. Hospital-level outcomes across all observation-status stays have not been evaluated in relation to the presence of a dedicated OU in the hospital.

OBJECTIVE

To compare observation-status stay outcomes in hospitals with and without a dedicated OU.

DESIGN

Cross-sectional analysis of hospital administrative data.

METHODS

Observation-status stay outcomes were compared in hospitals with and without a dedicated OU across 4 categories: (1) LOS, (2) standardized costs, (3) conversion to inpatient status, and (4) return care.

SETTING/PATIENTS

Observation-status stays in 31 free-standing children's hospitals contributing observation patient data to the Pediatric Health Information System database, 2011.

RESULTS

Fifty-one percent of the 136,239 observation-status stays in 2011 occurred in 14 hospitals with a dedicated OU; the remainder were in 17 hospitals without. The percentage of observation-status same-day discharges was higher in hospitals with a dedicated OU compared with hospitals without (23.8 vs 22.1, P < 0.001), but risk-adjusted LOS in hours and total standardized costs were similar. Conversion to inpatient status was higher in hospitals with a dedicated OU (11.06%) compared with hospitals without (9.63%, P < 0.01). Adjusted odds of return visits and readmissions were comparable.

CONCLUSIONS

The presence of a dedicated OU appears to have an influence on same-day and morning discharges across all observation-status stays without impacting other hospital-level outcomes. Inclusion of location of care (eg, dedicated OU, inpatient unit, emergency department) in hospital administrative datasets would allow for more meaningful comparisons of models of hospital care.

Failure of Emergency Department Observation Unit Treatment for Skin and Soft Tissue Infections

BACKGROUND

The effectiveness of observation unit (OU) management of skin and soft tissue infections (SSTI) has not been fully evaluated.

OBJECTIVE

This study was performed to determine the rate and risk factors.

METHODS

Retrospective cohort study of children ages 2 months to 18 years admitted to the OU for an SSTI between 2007 and 2010 from a pediatric emergency department (ED). Failure of OU therapy was defined as subsequent inpatient ward admission, re-admission after discharge from OU, initial or repeat incision and drainage after OU admission, or change in antibiotic therapy. Demographic, clinical, and lesion characteristics were collected. Comparative analyses were conducted to determine factors associated with OU failure; prolonged OU admission, defined as length of stay ≥ 36 h was evaluated.

RESULTS

One hundred ninety-two (63.2%) of 304 subjects with SSTI were eligible; mean age was 6.2 ± 5.3 years, and 52% were male. Fever (≥38°C) in the ED was present for 77 (40%). Most lesions were skin abscesses (53%) and were located on the lower extremity (36%) and buttock/genitourinary (21%). OU treatment failure occurred in 22% (95% confidence interval [CI] 16.5-28.3), primarily due to inpatient admission. Fever on ED presentation was significantly associated with OU failure (odds ratio 2.02; 95% CI 1.02-4.02). Demographics, body site, presence of abscess, and methicillin-resistant Staphylococcus aureus were not associated with OU failure. Prolonged OU admission occurred in 18 subjects (9.4%).

CONCLUSION

SSTI can be successfully treated in the OU, though febrile children with SSTI are at risk for OU treatment failure and should be considered for inpatient admission.

Best practices for improving flow and care of pediatric patients in the emergency department

This report provides a summary of best practices for improving flow, reducing waiting times, and improving the quality of care of pediatric patients in the emergency department.

Resource utilization of pediatric patients exposed to venom

BACKGROUND AND OBJECTIVE

Treating envenomation with antivenom is costly. Many patients being treated with antivenom are in observation status, a billing designation for patients considered to need care that is less resource-intensive, and less expensive, than inpatient care. Observation status is also associated with lower hospital reimbursements and higher patient cost-sharing. The goal of this study was to examine resource utilization for treatment of envenomation under observation and inpatient status, and to compare patients in observation status receiving antivenom with all other patients in observation status.

METHODS

This was a retrospective study of patients with a primary diagnosis of toxic effect of venom seen during 2009 at 33 freestanding children's hospitals in the Pediatric Health Information System. Data on age, length of stay, adjusted costs (ratio cost to charges), ICU flags, and antivenom utilization were collected. Comparisons were conducted according to admission status (emergency department only, observation status, and inpatient status), and between patients in observation status receiving antivenom and patients in observation status with other diagnoses.

RESULTS

A total of 2755 patients had a primary diagnosis of toxic effect of venom. Of the 335 hospitalized, either under observation (n = 124) or inpatient (n = 211) status, 107 (31.9%) received antivenom. Of those hospitalized patients receiving antivenom, 24 (22.4%) were designated as observation status. Costs were substantially higher for patients who received antivenom and were driven by pharmacy costs (mean cost: $17 665 for observation status, $20 503 for inpatient status). Mean costs for the 47 162 patients in observation status with other diagnoses were $3001 compared with $17 665 for observation-status patients who received antivenom.

CONCLUSIONS

Treatment of envenomation with antivenom represents a high-cost outlier within observation-status hospitalizations. Observation status can have financial consequences for hospitals and patients.

Effect of using pediatric emergency department virtual observation on inpatient admissions and lengths of stay

OBJECTIVE

To determine whether using emergency department (ED) virtual observation for select pediatric conditions decreases admission rates for these conditions, and to examine effects on length of stay.

METHODS

The option of ED virtual observation care for 9 common pediatric conditions was introduced in 2009; associated order sets were developed. Retrospective secondary analyses of administrative data from our tertiary care pediatric ED and children's hospital were performed for the year before (year 0) and after (year 1) this disposition option was introduced. The proportion of visits admitted to the inpatient unit and length of stay (LOS) were determined for all visits considered eligible for ED virtual observation care on the basis of diagnosis codes for both study years.

RESULTS

There were 1614 observation-eligible visits in year 0 and 1510 in year 1. In year 1, 18% (n = 266) of observation-eligible visits received ED virtual observation care. Admission rates for observation-eligible visits were similar after this model of care was introduced (25% year 0, 29% year 1, P = .02). Median LOS for ED virtual observation visits was 8.8 hours (interquartile range 6.5-12.4). ED LOS was shorter for ED discharges (5.6 hours year 0, 5.1 hours year 1, P < .001) and unchanged for admissions (6.0 hours year 0, 5.8 hours, year 1, P = .41) after introducing ED virtual observation.

CONCLUSIONS

Admission rates for observation-eligible visits were not lower in the year after ED virtual observation care was introduced. LOS decreased for ED discharges and was unchanged for admissions. Reevaluation of the effects of pediatric ED virtual observation on admission rates and LOS after longer periods of use is indicated.

Treatment of skin and soft tissue infections in a pediatric observation unit

OBJECTIVES

To report the success rate of observation unit (OU) treatment of pediatric skin and soft tissue infections (SSTIs) and to see if we could identify variables at the time of initial evaluation that predicted successful OU treatment.

METHODS

A retrospective review of children less than 18 years of age admitted for SSTI treatment to our OU from the emergency department between January 2003 and June 2009.

RESULTS

On records review, 853 patients matched eligibility criteria; median age was 5.2 years (interquartile range = 2.5-9 years). Of the 853 patients, 597 (70.0%) met the primary outcome criteria of successful OU discharge within 26 hours. Secondary analysis revealed that 82% of the patients achieved successful discharge from the OU within 48 hours. Although some laboratory variables demonstrated statistical association with success, none achieved a combination of high sensitivity and specificity to predict OU failure. OU success rates varied by location. Dental and face infections and those of the extremities or multiple sites demonstrated OU success rates higher than 65%, while infection of the groin, buttocks, trunk, or neck had success rates between 24% (neck) and 60% (groin). In multivariate analysis, only 3 variables remained significant. Unfavorable location was most strongly associated with OU failure, followed by C-reactive protein > 4 and then by erythrocyte sedimentation rate > 20.

CONCLUSIONS

Our findings suggest that successful OU treatment is possible in a large group of patients needing hospitalization for SSTIs. Consideration of infection location may assist the emergency department clinician in determining the most appropriate unit for admission.

Resource utilization for observation-status stays at children's hospitals

BACKGROUND AND OBJECTIVE

Observation status, in contrast to inpatient status, is a billing designation for hospital payment. Observation-status stays are presumed to be shorter and less resource-intensive, but utilization for pediatric observation-status stays has not been studied. The goal of this study was to describe resource utilization characteristics for patients in observation and inpatient status in a national cohort of hospitalized children in the Pediatric Health Information System.

METHODS

This study was a retrospective cohort from 2010 of observation- and inpatient-status stays of ≤2 days; all children were admitted from the emergency department. Costs were analyzed and described. Comparison between costs adjusting for age, severity, and length of stay were conducted by using random-effect mixed models to account for clustering of patients within hospitals.

RESULTS

Observation status was assigned to 67 230 (33.3%) discharges, but its use varied across hospitals (2%-45%). Observation-status stays had total median costs of $2559, including room costs and $678 excluding room costs. Twenty-five diagnoses accounted for 74% of stays in observation status, 4 of which were used for detailed analyses: asthma (n = 6352), viral gastroenteritis (n = 4043), bronchiolitis (n = 3537), and seizure (n = 3289). On average, after risk adjustment, observation-status stays cost $260 less than inpatient-status stays for these select 4 diagnoses. Large overlaps in costs were demonstrated for both types of stay.

CONCLUSIONS

Variability in use of observation status with large overlap in costs and potential lower reimbursement compared with inpatient status calls into question the utility of segmenting patients according to billing status and highlights a financial risk for institutions with a high volume of pediatric patients in observation status.

The utility of the emergency department observation unit for children with abdominal pain

OBJECTIVE

This study aimed to determine the outcome of children with unclear etiology for acute abdominal pain admitted to the emergency department observation unit (EDOU).

METHODS

This is a retrospective cohort study of children 18 years or younger who presented with acute abdominal pain to a tertiary pediatric ED and were observed in the EDOU. Children with alternative explanations for abdominal pain were excluded. Patients were classified based on disposition, and data were analyzed using χ tests.

RESULTS

There were 237 patients included in the study (median age, 9 years; 46% male). Mean length of stay in EDOU was 14.4 hours. Fifty-four percent were evaluated by surgery. Two hundred (84%) were discharged; 37 (16%) were admitted, of whom 22 (9%) underwent surgical intervention (13 appendectomies, 6 ovarian cystectomies, 2 small-bowel obstructions, 1 cholecystectomy). Eight had acute appendicitis on pathology reports. The duration of symptoms, the presence of fever, nausea/vomiting, right-lower-quadrant pain, rebound tenderness, or leukocytosis greater than 10,000 cells/μL did not predict admission. Patients with diarrhea were more likely to be discharged home (P = 0.02). Intravenous hydration (86%) and pain control (63%) were the most common interventions in the EDOU. Abdominal pain not otherwise specified and acute gastroenteritis were the 2 most common discharge diagnoses. Eight (4%) of the 200 discharged patients returned to the ED within 48 hours, and all were discharged home from the ED.

CONCLUSIONS

The majority of children admitted to the EDOU with abdominal pain have nonsurgical causes of abdominal pain. The EDOU provides a reasonable alternative for monitoring these patients pending disposition.