Regular Medications in the Emergency Department Short Stay Unit (ReMedIES): Can Prescribing be Improved Without Increasing Resources?

Background: Hospital medication errors are frequent and may result in adverse events. Data on non-prescription of regular medications to emergency department short stay unit patients is lacking. In response to local reports of regular medication omissions, a multi-disciplinary team was tasked to introduce corrective emergency department (ED) process changes, but with no additional financing or resources. Aim: To reduce the rate of non-prescription of regular medications for patients admitted to the ED Short Stay Unit (SSU), through process change within existing resource constraints. Methods: A pre- and post-intervention observational study compared regular medication omission rates for patients admitted to the ED SSU. Included patients were those who usually took regular home medications at 08:00 or 20:00. Omissions were classified as clinically significant medications (CSMs) or non-clinically significant medications (non-CSMs). The intervention included reinforcement that the initially treating acute ED doctor was responsible for prescription completion, formal checking of prescription presence at SSU handover rounds, double-checking of prescription completeness by the overnight SSU lead nurse and junior doctor, and ED pharmacist medication reconciliation for those still identified as having regular medication non-prescription at 07:30. Results: For the 110 and 106 patients in the pre- and post-intervention periods, there was a non-significant reduction in the CSM omission rate of -11% (95% CI: -23 to 2), from 41% (95% CI: 32-50) to 30% (95% CI: 21-39). Conclusion: Non-prescription of regular CSMs for SSU patients was not significantly reduced by institution of work practice changes within existing resource constraints.

Clinical Pharmacist Led Medication Reconciliation Program in an Emergency Department Observation Unit

Objectives: Medication reconciliation is the process of comparing a patient's hospital medication orders to all of the medications that the patient has been taking prior to admission. The primary aim of this study was to evaluate the effectiveness of pharmacist-led medication reconciliation in reducing ED visit rates. The secondary aim of this study was to evaluate if a clinical pharmacist reduces medication errors in an ED observation unit (OBS). Methods: This was a retrospective, IRB approved, chart review conducted at New York University Langone Health-Tisch Hospital. The study defines the year before a clinical pharmacist was present on the unit (July 5, 2016 through July 4, 2017) as the control group and the first year a clinical pharmacist was present on the unit (July 5, 2017 through July 4, 2018) as the intervention group. The primary endpoint was 30-day ED re-visits. The secondary endpoints were 60-and 90-day ED re-visits, number, type and severity of medication history and reconciliation discrepancies. Results: The primary endpoint of 30-day ED visits occurred in 153 patients in the no pharmacist group and 88 patients in the OBS clinical pharmacist group (19.1% vs 9.9%, P < .00001). The secondary endpoint of 60- day ED visits occurred in 53 patients in the no pharmacist group and 39 patients in the OBS clinical pharmacist group (8.2% vs 4.9%, P = .01). The secondary endpoint of 90- day ED visits occurred in 31 patients in the no pharmacist group and 26 patients in the OBS clinical pharmacist group (5.2% vs 3.4%, P = .01). Conclusion: The benefits of having a clinical pharmacist perform medication reconciliation are highlighted by the reduction in ED visits, cost savings, and the prolific amount of errors corrected.

Emergency Department Observation Unit Patients Want Evaluation and Treatment for Hypercholesterolemia: A Health Belief Model Study

BACKGROUND

Hypercholesterolemia (HCL) is common among emergency department (ED) and ED observation unit (EDOU) patients with chest pain but is not typically addressed in these settings. The objective of this study was to assess patient attitudes towards EDOU-based HCL care using the Health Belief Model.

METHODS

We conducted a cross-sectional survey study among 100 EDOU patients ≥18 years-old evaluated for chest pain in the EDOU of a tertiary care center from September 1, 2020, to November 01, 2021. Five-point Likert-scale surveys were used to assess each Health Belief Model domain: Cues to Action, Perceived Susceptibility, Perceived Barriers, Perceived Self-Efficacy, and Perceived Benefits. Responses were categorized as agree or do not agree.

RESULTS

The participants were 49.0% (49/100) female, 39.0% (39/100) non-white, and had a mean age of 59.0 ± 12.4 years. Most (83.0% [83/100, 95% confidence interval (CI), 74.2%-89.8%]) agreed the EDOU is an appropriate place for HCL education and 52.0% (52/100, 95% CI, 41.8%-62.1%) were interested in talking with their EDOU care team about HCL. Regarding Perceived Susceptibility, 88.0% (88/100, 95% CI, 80.0%-93.6%) believed HCL to be bad for their health, while 41.0% (41/100, 95% CI, 31.3%-51.3%) believed medication costs could be a barrier. For Perceived Self-Efficacy, 76.0% (76/100, 95% CI, 66.4%-84.0%) were receptive to taking medications. Overall, 95.0% (95/100, 95% CI, 88.7%-98.4%) believed managing HCL would benefit their health.

CONCLUSIONS

This Health Belief Model-based survey indicates high patient interest in EDOU-initiated HCL care. Patients reported high rates of Perceived Susceptibility, Self-Efficacy, and Benefits and a minority found HCL therapy costs a barrier.

Paediatric one-day admission: why and is it necessary?

Introduction

Paediatric patients admitted to the inpatient units from the emergency department (ED) are increasing, but the mean length of stay has fallen significantly. We aimed to determine the reasons behind paediatric one-day admissions in Singapore and to assess their necessity.

Methods

A retrospective study involving paediatric patients who were admitted from a general ED of an adult tertiary hospital to a paediatric tertiary hospital between 1 August 2018 and 30 April 2020. One-day admission was defined as an inpatient stay of less than 24 h from the time of admission to discharge. An unnecessary admission was defined as one with no diagnostic test ordered, intravenous medication administered, therapeutic procedure performed or specialty review made in the inpatient unit. Data were captured in a standardised form and analysed.

Results

There were 13,944 paediatric attendances - 1,160 (8.3%) paediatric patients were admitted. Among these, 481 (41.4%) were one-day admissions. Upper respiratory tract infection (62, 12.9%), gastroenteritis (60, 12.5%) and head injury (52, 10.8%) were the three most common conditions. The three most common reasons for ED admissions were inpatient treatment (203, 42.2%), inpatient monitoring (185, 38.5%) and inpatient diagnostic investigations (32, 12.3%). Ninety-six (20.0%) one-day admissions were unnecessary.

Conclusion

Paediatric one-day admissions present an opportunity to develop and implement interventions targeted at the healthcare system, the ED, the paediatric patient and their caregiver, in order to safely slow down and perhaps reverse the trend of increased hospital admissions.

Characteristics and Outcomes of Patients with Cancer Pain Placed in an Emergency Department Observation Unit

Pain remains an undertreated complication of cancer, with poor pain control decreasing patients’ quality of life. Traditionally, patients presenting to an emergency department with pain have only had two dispositions available to them: hospitalization or discharge. A third emerging healthcare environment, the emergency department observation unit (EDOU), affords patients access to a hospital’s resources without hospitalization. To define the role of an EDOU in the management of cancer pain, we conducted a retrospective study analyzing patients placed in an EDOU with uncontrolled cancer pain for one year. Patient characteristics were summarized using descriptive statistics and predictors of disposition from the EDOU and were identified with univariate and multivariate analyses. Most patients were discharged home, and discharged patients had low 72-hour revisit and 30-day mortality rates. Significant predictors of hospitalization were initial EDOU pain score (odds ratio (OR) = 1.12; 95% CI 1.06−1.19; p < 0.001) and supportive care (OR = 2.04; 95% CI 1.37−3.04; p < 0.001) or pain service (OR = 2.67; 95% CI 1.63−4.40; p < 0.001) consultations. We concluded that an EDOU appears to be the appropriate venue to care for a subsegment of patients presenting to an emergency department with cancer pain, with patients receiving safe care as well as appropriate consultation and admission when indicated.

The Impact of Accelerated Diagnostic Protocol Implementation on Chest Pain Observation Unit Utilization

BACKGROUND

Data evaluating the impact of the history, ECG, age, risk factors, and troponin (HEART) Pathway on observation unit (OU) use is limited. The objective of this study is to determine how HEART Pathway implementation affects OU use.

METHODS

An analysis of OU registry data from October 2012 to October 2016, 2 years before and after HEART Pathway implementation at an academic medical center, was conducted. Adult patients placed in the OU for chest pain were included. The proportion of patients placed in the OU chest pain protocol per total OU volume and hospitalization and myocardial infarction (MI) rates were determined. Proportions before versus after implementation were compared using χ2 tests and age was compared using a Mann-Whitney U test.

RESULTS

During the study period, 1688 patients with chest pain before HEART Pathway implementation and 1692 after were included. The proportion of chest pain patients in the OU per total OU volume decreased following implementation from (57% [1688/2968] to 43.6% [1692/3882]; P < 0.001). Before HEART Pathway implementation, the hospitalization rate was 10.4% (175/1688) versus 12.4% (210/1692) after (P = 0.07). More patients were diagnosed with MI following implementation (0.8% [14/1665] vs. 2.0% [33/1686]; P = 0. 008). Median age was older postimplementation (52 years [IQR: 45-59 years] vs. 54 years [IQR: 48-64 years]; P < 0. 001).

CONCLUSIONS

HEART Pathway implementation resulted in management of higher risk patients in the OU. Following implementation, OU chest pain patients were older and were more likely to be hospitalized or diagnosed with MI.

Evaluation of Process Improvement Interventions on Handoff Times between the Emergency Department and Observation Unit

BACKGROUND

Mitigating hospital crowding requires judicious use of inpatient resources, making Emergency Department Observation Units (EDOUs) an increasingly vital destination for patients that are not suitable for discharge. Maximizing the utility of the EDOU hinges on efficient patient transfers and safe provider communication, which may be accomplished with asynchronous handoff and an emphasis on pull-through operations.

OBJECTIVE

The purpose of this study was to assess the impact of an electronic, asynchronous handoff replacing verbal handoff on transfer times from the Emergency Department (ED) to the EDOU.

METHODS

A retrospective observational study was performed with patients transferred to the EDOU throughout several process improvement measures focused on asynchronous handoff. Multivariable linear regression analysis was used to determine the effect that these process improvements had on the time from EDOU bed assignment to patient transfer.

RESULTS

There were 14,996 EDOU stays during the 20-month period included in the analysis. Time from EDOU bed assignment to patient transfer decreased significantly with all three interventions studied. An auto-page to the clinicians notifying them of a ready bed reduced the mean time to transfer by 10.1 min (p < 0.0001), asynchronous nursing handoff reduced it by 3.57 min (p = 0.0299), and asynchronous clinician handoff reduced it by 14.67 min (p < 0.0001).

CONCLUSION

Introducing automatic pages regarding bed status and converting the handoff process from a verbal model to an asynchronous, electronic handoff were effective ways to reduce the time from bed assignment to transfer out of the ED for patients being sent to the EDOU.

Management of acute pyelonephritis in the emergency department observation unit

INTRODUCTION

This study aimed to assess the effectiveness of the emergency department observation unit (EDOU) for patients with acute pyelonephritis in a Singapore tertiary academic medical centre.

METHODS

We reviewed the clinical records of consecutive patients who presented with pyelonephritis between 1 July 2012 and 31 October 2014 to collect information on demographics, symptoms, signs, laboratory and radiological results, treatment, and clinical outcomes.

RESULTS

Of 459 emergency department (ED) patients who were identified as having pyelonephritis, 164 (35.7%) were managed in the EDOU. Successful management in the EDOU was achieved in 100 (61.0%) patients. Escherichia coli was the predominant (64.6%) micro-organism in urine cultures and was positive in 106 patients. Patients diagnosed with acute pyelonephritis who were successfully managed in the EDOU had a lower incidence of nausea (32.0% vs. 60.9%, p < 0.001) and vomiting (15.0% vs. 50.0%, p < 0.001) compared to those who were not successful.

CONCLUSION

EDOU is useful for both observation and treatment of patients with acute pyelonephritis. Urine cultures are sufficient for the identification of the culprit micro-organism. Patients who present with prominent symptoms of vomiting should have routine administration of antiemetics, while consideration for second-line antiemetics is recommended for those with persistent symptoms.

Role of echocardiography in diagnostic evaluation of patients admitted to observation unit

BACKGROUND

Syncope is a transient loss of consciousness due to transient decrease in cerebral perfusion. Syncope accounts for a 3-6% of all emergency department visits. Etiology of syncope can be neural, cardiogenic, or vascular. Previous studies have evaluated the types and management of syncope. Echocardiography is a commonly used test in the evaluation of causes of syncope. Whether the benefit compared to financial burden of this diagnostic study is in all subsets of syncope cases remains unclear.

AIM

To evaluate the impact of echocardiography in the diagnostic evaluation of syncope and to evaluate the subset of patients that would benefit more from this diagnostic imaging.

METHODS

We performed a retrospective chart review of patients > 18 years of age with a primary diagnosis of syncope in a period of January 1^st 2015-January 31^st 2017. Our inclusion criteria included patients > 18 years of age who were admitted to the observation floor with the primary complaint as syncope, had a normal or abnormal physical examination for syncope, had a normal or abnormal electrocardiogram during admission, had an echocardiography performed at admission. Our exclusion criteria included patients with seizures, hypoglycemia, myocardial infarction, patients who didn't get echocardiography, and patients who had a positive marker of cardiac injury.

RESULTS

A total of 369 patients were initially identified with a primary diagnosis of syncope, however only 120 of these patients fulfilled our inclusion and exclusion criteria. A total of n=25 of included patients had either an abnormal physical exam or abnormal echocardiography. Among this "high risk" group, 24% (n=6) of the patients had an abnormal finding on their transthoracic echocardiography. On the other hand, in the "low risk" group with a normal physical examination and electrocardiogram (EKG), 14 had a trans-thoracic echocardiography (TTE) positive for cause of syncope, that led to a change in medication, workup, or intervention in 6.7% (n=8) of the patients.

CONCLUSION

The analysis of our study suggested that the diagnostic yield of transthoracic echocardiography in syncope is very limited in the absence of an abnormal physical exam or electrocardiogram, and it increase the health care cost burden with no additional benefits.

Factors Affecting Length of Stay for Observation Patients

Objectives

The objective of this study was to determine whether the addition of a case manager and a physician advisor to the observation unit would decrease the length of stay (LOS) of observation patients.

Study design

This retrospective, observational study for observation patients was conducted in 2017.

Methods

At a tertiary-care, medium-sized, urban, community hospital, the LOS for all observation patients in 2017 (2, 981 clinical decision unit [CDU] patients and 1,248 non-cohort patients) was studied. Interventions studied were the addition of unit-based case manager and physician advisor to observation patient treatment teams.

Results

Patients assigned to the CDU had a shorter LOS than scattered patients, p < 0.0005. After the data was controlled for changes in LOS on inpatients using analysis of covariance (ANCOVA), none of the interventions resulted in statistically significant effects on LOS for CDU or scattered patients. Season, day of the week, the month of the year, and the presence of residents/medical students did not have any effect on LOS. Patients arriving at night had significantly shorter LOS than those arriving during the day or evening, p = 0.035 and p = 0.029, respectively.

Conclusions

Placing observation patients in a single unit is effective for decreasing LOS. The addition of case managers or physician advisors may not be an effective strategy to address the LOS. The presence of trainees does not hinder patient flow.

Undiagnosed Diabetes in Patients Admitted to a Clinical Decision Unit from the Emergency Department: A Retrospective Review

Objectives Diabetes is a debilitating disease that affects the way the body uses or produces insulin. Research evaluating the usefulness in screening patients admitted to a clinical decision unit (CDU) from the emergency department (ED) has been limited. Methods A retrospective chart review of patients admitted to a CDU from the ED was performed. Patients included were > 18-year-old who were observed in the CDU, had blood glucose drawn greater than eight hours after admission, and who had not been previously diagnosed with diabetes. Age, sex, and fasting glucose level were collected. The analysis was done to evaluate the percentage of patients undiagnosed and at risk for diabetes mellitus by assessing fasting blood glucose the morning after admission. Results Study revealed that 27.8% of the patients analyzed in this study had fasting blood glucose levels meeting or exceeding the diagnostic threshold of 126 mg/dL and could potentially have undiagnosed diabetes. Conclusion Screening patients admitted to a CDU from the emergency department identified that 27.8% had fasting plasma glucose levels ≥ 126 mg/dL. Consideration should be made to obtain a fasting blood glucose level in those without a previous diagnosis of diabetes who are observed overnight in a CDU.

Comparative efficiency of exercise stress testing with and without stress-only myocardial perfusion imaging in patients with low-risk chest pain

OBJECTIVES

To compare major adverse cardiac event (MACE), downstream resource utilization, and direct cost of care for low-risk chest pain patients observed in the clinical decision unit (CDU) with exercise treadmill testing (ETT) and with stress-only myocardial perfusion imaging (sMPI).

BACKGROUND

CDUs are poised to increase efficiency and resource utilization. However, the optimal testing strategy that would assure favorable outcomes while decreasing cost is not defined.

METHODS

1016 subjects from 2 locations were propensity score-matched (PSM) by age, gender, pre-test likelihood, Duke treadmill score, and test results. Outcomes were length of stay >24 hours, MACE (acute coronary syndrome, revascularization, cardiac death), downstream resource use (admission for chest pain, repeat testing, angiography), and mean direct cost per patient.

RESULTS

PSM yielded 680 patients (340 matches). 98% of all tests were normal. 96.6% of patients were discharged from the CDU within 24 hours but twice as many exceeded 24 hours in the sMPI group. There were no cardiac deaths. MACE rate was 1.47% at 72 hours and 1% at 1 year. Downstream resource use was 4.82% at 72 hours, and 7.69% at 1 year. The sMPI group was event-free longer than the ETT group reflecting less repeat testing. The mean direct cost was 30% higher for sMPI ($3168.70) vs. ETT ($2226.96).

CONCLUSION

Low-risk chest pain patients in the observation unit had low MACE rate, not different for ETT vs. sMPI. The majority of ETT and sMPI tests were normal. The sMPI reduced additional testing, but resulted in greater expense and longer stay.

Evaluation of hospital length of stay and revenues as a function of admission mode, clinical pathways including observation unit stay and hospitalization characteristics

OBJECTIVES

Hospital length of stay (days) and revenues per day (euros) could be different depending on admission mode. To determine the impact of admission mode as a function of clinical pathway, we conducted the present study. Data sources: We included 159,206 admissions to three academic hospitals during a four-year period. Data were obtained from the electronic system of the hospital trust.

STUDY DESIGN

A case (through-emergency department)-control (elective (EA)) study was conducted (77,052), matched by age, stay severity and type, disease-related group, and discharge mode. Principal findings: Through-emergency department were significantly elderly, more severe, had more intensive care stays, a higher mortality rate, longer length of stay (days) (9.5 ± 12 vs. 6.8 ± 9.5; p < 0.0001), and lower revenues per day (647 ± 451 vs. 721 ± 422; p = 0.01). In case-control study, mean differences between cases and controls were: longer length of stay -0.64 and revenues per day -75.6; for ≥75 years -1.2 and -102.1; medical -0.9 and -90.4; and discharge to facilities care centers -1.5 and -81.8. Among cases, 40% had a stay in observation unit before being admitted in hospital ward. Differences were strongly reduced for patients who did not go to observation unit before being admitted. Differences were reduced from 0.64 to 0.2 days for length of stay and from 79 to 41 euros for revenues per day when patients did not stay in observation unit before being admitted.

CONCLUSIONS

We conclude that admission mode is associated with length of stay and revenues. However, as differences are weak, elective admissions should not be prioritized on economic arguments. Otherwise, our study indicates that among through-emergency department admissions, observation unit stay is associated with longer length of stay and lower revenues.

System outcomes associated with a pediatric emergency department clinical decision unit

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effect of a Multi-Diagnosis Observation Unit on Emergency Department Length of Stay and Inpatient Admission Rate at Two Canadian Hospitals

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.

How a short stay unit can reduce children's waiting times

Admitting children to emergency departments (EDs) often places them in an environment better suited to the treatment of adult patients. These children are often triaged and treated as adults, resulting in children being given the wrong triage categories and having their treatment delayed. EDs have problems giving drugs to children, staff are unfamiliar with children's emergency care, and children find EDs frightening. A paediatric emergency short stay unit (PESSU) was opened at Caboolture Hospital, Queensland, Australia, in January 2014. Admission to the PESSU has significantly reduced waiting times for children arriving at the ED and enabled specialist nursing and medical care to be provided quickly. This has been supported by the development of the paediatric flow nurse role ( Gray et al 2016 ).

Impact of Frailty and Sociodemographic Factors on Hospital Admission From an Emergency Department Observation Unit

Understanding factors associated with an increased risk of hospital admission from emergency department (ED) observation units (OUs) could be valuable in disposition decisions. To evaluate the impact of frailty and sociodemographic factors (SDFs) on admission risk, patients in an ED OU were surveyed. Survey measures included SDFs, social habits, and frailty measured by the Katz Index of Independence in Activities of Daily Living. Of 306 surveyed, 18% were admitted and 82% were discharged. Demographics were similar between groups. More admitted patients responded positively to the Katz Index (28% vs 13%, P = .007; odds ratio = 2.73; 95% CI = 1.35-5.51). College graduation and current employment favored the discharge group, while admitted patients were more likely to receive Social Security disability insurance. Frailty remained associated with admission on multivariable analysis. Frailty, disability insurance, and lower education are predictors of admission from an OU and could serve as screening criteria in disposition decisions.

Prevalence of undiagnosed dysglycemia in an emergency department observation unit

BACKGROUND

The proposed 2015 US Preventive Services Task Force guidelines recommend diabetes screening for individuals ≥45 years or demonstrating other risk factors for dysglycemia. Still, many patients with dysglycemia remain undiagnosed, and opportunities for early intervention are lost.

METHODS

To test novel approaches for diagnosis using the haemoglobin A1c (HbA1c ) test, we screened adult patients who were admitted to an observation unit from the emergency department with no known history of pre-diabetes or diabetes.

RESULTS

Of 256 subjects, 9% were newly diagnosed with diabetes and 52% were newly diagnosed with pre-diabetes. Of those aged 18-29 years, 33% were newly diagnosed with dysglycemia, while 55% of those aged 30-44 years and 70% of those aged ≥45 years were newly diagnosed with dysglycemia.

CONCLUSIONS

Our results suggest that regardless of age, a large proportion of patients in the emergency department observation unit have undiagnosed dysglycemia, an important finding given the large number of observation admissions. Copyright © 2015 John Wiley & Sons, Ltd.

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.

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.

Factors associated with prolonged observation services stays and the impact of long stays on patient cost

BACKGROUND

Patients are treated using observation services (OS) when their care needs exceed standard outpatient care (i.e., clinic or emergency department) but do not qualify for admission. Medicare and other private payers seek to limit this care setting to 48 hours.

DATA SOURCE/STUDY SETTING

Healthcare Cost and Utilization Project data from 10 states and data collected from two additional states for 2009.

STUDY DESIGN

Bivariate analyses and hierarchical linear modeling were used to examine patient- and hospital-level predictors of OS stays exceeding 48 (and 72) hours (prolonged OS). Hierarchical models were used to examine the additional cost associated with longer OS stays.

PRINCIPAL FINDINGS

Of the 696,732 patient OS stays, 8.8 percent were for visits exceeding 48 hours. Having Medicaid or no insurance, a condition associated with no OS treatment protocol, and being discharged to skilled nursing were associated with having a prolonged OS stay. Among Medicare patients, the mean charge for OS stays was $10,373. OS visits of 48-72 hours were associated with a 42 percent increase in costs; visits exceeding 72 hours were associated with a 61 percent increase in costs.

CONCLUSION

Patient cost sharing for most OS stays of less than 24 hours is lower than the Medicare inpatient deductible. However, prolonged OS stays potentially increase this cost sharing.

Pediatric observation units in the United States: a systematic review

BACKGROUND

As more efficient and value-based care models are sought for the US healthcare system, geographically distinct observation units (OUs) may become an integral part of hospital-based care for children.

PURPOSE

To systematically review the literature and evaluate the structure and function of pediatric OUs in the United States.

DATA SOURCES

Searches were conducted in Medline, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Health Care Advisory Board (HCAB), Lexis-Nexis, National Guideline Clearinghouse, and Cochrane Reviews, through February 2009, with review of select bibliographies.

STUDY SELECTION

English language peer-reviewed publications on pediatric OU care in the United States.

DATA EXTRACTION

Two authors independently determined study eligibility. Studies were graded using a 5-level quality assessment tool. Data were extracted using a standardized form.

DATA SYNTHESIS

A total of 21 studies met inclusion criteria: 2 randomized trials, 2 prospective observational, 12 retrospective cohort, 2 before and after, and 3 descriptive studies. Studies present data on more than 22,000 children cared for in OUs, most at large academic centers. This systematic review provides a descriptive overview of the structure and function of pediatric OUs in the United States. Despite seemingly straightforward outcomes for OU care, significant heterogeneity in the reporting of length of stay, admission rates, return visit rates, and costs precluded our ability to conduct meta-analyses. We propose standard outcome measures and future directions for pediatric OU research.

CONCLUSIONS

Future research using consistent outcome measures will be critical to determining whether OUs can improve the quality and cost of providing care to children requiring observation-length stays.