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Pediatric OUs in the United States
The first observation units were implemented more than 40 years ago with the goal of reducing the number and duration of inpatient stays. Since then, observation units (OUs) have evolved as a safe alternative to hospitalization14 for the delivery of finite periods of care, typically less than 24 hours.58 Observation services allow for time to determine the need for hospitalization in cases that are unclear after their initial evaluation and treatment.9 Observation status is an administrative classification related to reimbursement that can be applied to patients whose diagnosis, treatment, stabilization, and discharge can reasonably be expected within 24 hours.10, 11 The site of care for observation is dependent in part upon existing facility structures; some institutions utilize virtual OUs within the emergency department (ED) or hospital ward, while others have dedicated, geographically distinct OUs, which may function as an extension of either the ED or inpatient settings.9
OUs have been instrumental in providing care to adult patients with chest pain, asthma, and acute infections.1218 Recently, there has been an increase in the number of publications from pediatric OUs in the United States and abroad. Observation may be a preferred model of care for select pediatric patients, as hospitalized children often experience brief stays.1921 Previous reviews on this model of care have combined adult and pediatric literature and have included research from countries with healthcare structures that differ considerably from the United States.2224 To date, no systematic review has summarized the pediatric OU literature with a focus on the US healthcare system.
As payers and hospitals seek cost‐effective alternatives to traditional inpatient care, geographically distinct OUs may become integral to the future of healthcare delivery for children. This systematic review provides a descriptive overview of the structure and function of pediatric OUs in the United States. We also scrutinize the outcome measures presented in the included publications and propose future directions for research to improve both observation unit care, as well as the care delivered to patients under observation status within general inpatient or ED settings.
Methods
Literature Search
With the assistance of a health services librarian, a search of the following electronic databases from January 1, 1950 through February 5, 2009 was conducted: 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. Key words used for the Boolean search are included in Appendix A. In addition, we conducted a manual search of reference lists from reviews, guidelines, and articles meeting inclusion criteria.
We included English language peer‐reviewed publications that reported on pediatric OU care in the United States. Studies were included if they reported outcomes including lengths of stay, admission from observation rates, return visit rates, costs or charges. Descriptive publications of pediatric OU structure and function were also included. Studies were excluded if they were conducted outside the United States, evaluated psychiatric or intensive care, reported on observation status in an ED without an OU or observation status on a traditional inpatient ward. Two reviewers (M.M. and C.K.) identified articles for inclusion. Any disagreements between the reviewers were resolved by discussion and consensus agreement. Interrater reliability was assessed using the kappa statistic.
Quality Assessment
The quality of each study was rated using the Oxford Centre for Evidence‐based Medicine levels of evidence.25 With this system, levels of evidence range from 1a (homogeneous systematic review of randomized, controlled trials) to 5 (expert opinion without explicit critical appraisal).
Data Synthesis
Data on study design, OU characteristics, patient populations, and outcomes were extracted using a standardized form. Heterogeneity of study design, interventions, and outcomes precluded the ability to conduct meta‐analyses.
Results
A systematic search of the electronic databases identified 222 unique citations (Figure 1). A total of 107 abstracts were evaluated. We identified 48 articles for full‐text review, of which 18 met inclusion criteria. Hand search of references yielded 24 additional articles, of which 3 met inclusion criteria. Interrater agreement for selected articles was high at 98% (kappa = 0.85).
Observation Unit Characteristics
The majority of research on OUs has been conducted at large academic pediatric centers. One publication was from a community hospital.26 These studies present data on more than 22,000 children cared for in OUs of 11 hospitals over a 32‐year time span. Most studies were level 2 evidence: 2b, retrospective cohort studies and low‐quality randomized, controlled trials; or 2c, outcomes research. Three were descriptive and not assigned a formal evidence level.2729
Table 1 highlights general features of U.S. pediatric OUs. Five institutions renovated or expanded clinical space in order to open the OU.27, 2932 Units ranged in size from 3 to 23 beds. The OU was located in or near the ED in all but 2 hospitals, which had ward‐based units. The ED was the primary entry point into the OU with only 2 open model units accepting patients from other settings.5, 32 The annual number of observation cases ranged from 1000 to 3000 in children's hospitals. Approximately 500 ward‐based observation cases per year were cared for in the single community hospital studied. Three reports included time trends showing increased OU utilization over study years.5, 30, 31
| Publication (Year); Condition | Study Design; Level of Evidence; Time Frame; Sample Size | Hospital; Observation Setting; Year Opened | Site | Beds | Entry Point | Staffing; Physicians; Nurses |
|---|---|---|---|---|---|---|
| ||||||
| Gururaj et al.43 (1972); all conditions | Retrospective cohort; 2c; 1 year; 437 cases under observation | King's County Downstate Brooklyn; short‐stay unit | ED | 3 | Not reported | Pediatric residents; general pediatricians |
| Ellerstein and Sullivan,32 (1980); all conditions | Retrospective cohort; 2c; 6 years; 5858 cases of unscheduled care plus 1403 elective surgery cases | Children's Hospital Buffalo; observation unit; 1972 | ED | 8 | ED, clinic, procedure/OR | Primary care pediatricians; other specialists; pediatric residents |
| O'Brien et al.37 (1980); asthma | Retrospective cohort; 2c; 1 month; 434 cases of asthma, 328 discharged directly from ED, 106 treated in holding unit | Children's National DC; holding unit | ED | 6 | ED | 1‐2 pediatric residents; 1‐2 nurses |
| Willert et al.35 (1985); asthma | Randomized*; 2b; 578 cases of asthma; 166 cases 1.5 hours postaminophylline, 103 randomized, 52 to holding unit | Children's Memorial Chicago; holding room | ED | 5 | ED | General pediatricians; pediatric residents; PEM nurses |
| Listernick et al.38 (1986); dehydration | Randomized; 2b; 29 cases of dehydration; 22 to holding unit | Children's Memorial Chicago | ||||
| Balik et al.31 (1988); all conditions | Descriptive; none given | Minneapolis Children's; short‐stay unit observation area; 1985 | Day surgery area adjacent to ED | Not reported | Not reported | General pediatricians; pediatric nurses (shared with ED) |
| Marks et al.7 (1997); all conditions | Retrospective cohort; 2c; 5 months; 968 cases in short‐stay unit | Children's Hospital Boston; short‐stay unit; 1994 | Ward | 4‐18 | ED | Primary care pediatricians; PEM physicians; pediatric residents; pediatric nurses; 1:6 nurse:patient ratio |
| Marks et al.7 (1997); asthma | Pre‐post; 2b; 400 cases of asthma; 102 pre/298 post short‐stay unit | Children's Hospital Boston | ||||
| Wiley et al.6 (1998); all conditions | Retrospective cohort; 2c; 1 year; 805 cases of unscheduled observation; plus 595 scheduled cases | Connecticut Children's; outpatient extended treatment site | ED | 10 | Not reported | PEM physicians; other specialists; 1:5 nurse:patient ratio |
| Scribano et al.65 (2001); all conditions | Retrospective cohort; 2b; 2 years; 1798 cases under observation | Connecticut Children's | ||||
| Leduc et al.30 (2002); all conditions | Retrospective cohort; 2c; 6 months; 686 cases under observation (4.8% of ED visits) | Children's Hospital Denver; OU | ED | 6 | Not reported | Not reported |
| Bajaj and Roback,30 (2003); intussusception | Retrospective cohort; 2b; 4.5 years; 78 cases of intussusception (51 under observation) | Children's Hospital Denver | ||||
| Wathen et al.36 (2004); dehydration | Convenience sample; 2c; 10 months; 182 cases of dehydration (48 under observation) | Children's Hospital Denver | ||||
| Crocetti et al.26 (2004); all conditions | Retrospective cohort; 2b; 2 years; 956 cases under observation | John Hopkin's Bayview; observation status beds; 1997 | Ward | Not reported | 99% ED 1% other location | General pediatricians covering ED and ward |
| Silvestri et al.29 (2005); all conditions | Descriptive; none given | Children's Hospital of Philadelphia; OU; 1999 | ED | 12 | ED | PEM physicians; PEM fellows; urgent care pediatricians; ED nurse practitioner; inpatient nurses |
| Alpern et al.34 (2008); all conditions | Prospective cohort; 1b; 30 months; 4453 cases under observation | Children's Hospital of Philadelphia | ||||
| Thomas27 (2000); all conditions | Descriptive; none given | Primary Children's Medical Center; RTU; 1999 | ED | 22‐26 | ED, clinic, procedure/OR | PEM physicians; general pediatricians; other specialists; no residents |
| Zebrack et al.25 (2005); all conditions | Retrospective cohort; 2b; 2 years; 4189 cases of unscheduled observation plus 2288 scheduled cases | Primary Children's Medical Center | PEM nurses; 1:4 nurse:patient ratio | |||
| Miescier et al.40 (2005); asthma | Retrospective cohort; 2b; 2 years; 3029 asthma visits; 384 admitted, 301 observed, 161cases met inclusion | Primary Children's Medical Center | ||||
| Holsti et al.41 (2005); head injury | Retrospective cohort; 2b; 2 years; 827 CHI visits, 273 admitted, 285 observed, 284 cases met inclusion | Primary Children's Medical Center | ||||
| Greenberg et al.42 (2006); croup | Retrospective pre‐post; 2b; 1 year each; 694 croup cases pre‐RTU, 66 admitted; 789 croup cases post‐RTU, 33 admitted; 76 observed | Primary Children's Medical Center | ||||
| Mallory et al.33 (2006); dehydration | Retrospective cohort; 2b; 1 year; 430 dehydration cases under observation | Primary Children's Medical Center | ||||
Staffing and Workflow
Staffing models varied and have undergone transitions over time. Prior to 1997, general pediatricians primarily provided physician services. In more recent years, OUs have utilized pediatric emergency medicine (PEM) providers. Three of the 11 units allowed for direct patient care by subspecialists.5, 6, 32 One OU was staffed by nurse practitioners.29 OU nursing backgrounds included pediatrics, emergency medicine, or PEM.
Five institutions assembled multidisciplinary teams to define the unit's role and establish policies and procedures.7, 27, 2931 Workflow in the OU focused on optimizing efficiency through standardized orders, condition‐specific treatment protocols, and bedside charting.7, 26, 33 Several units emphasized the importance of ongoing evaluations by attending physicians who could immediately respond to patient needs. Rounds occurred as often as every 4 hours.5, 7 Two centers utilized combined physician‐nursing rounds to enhance provider communication.7, 34 No publications reported on patient transitions between sites of care or at shift changes.
Criteria for Observation
All 11 hospitals have developed protocols to guide OU admissions (Table 2). Nine publications from 4 OUs commented on treatments delivered prior to observation.33, 3542 The most commonly cited criteria for admission was approval by the unit's supervising physician. Utilization review was not mentioned as an element in the OU admission decision. Common OU exclusions were the need for intensive care or monitoring while awaiting an inpatient bed; however, these were not universal. Eight centers placed bounds around the duration of OU stays, with minimum stays of 2 hours and maximum stays of 8 to 24 hours.
| Hospital | Entry Criteria | Age Range | Time | Exclusion Criteria |
|---|---|---|---|---|
| ||||
| King's County, Downstate Brooklyn | Otherwise required inpatient admission | 0‐13 years | Maximum 24 hours | Not reported |
| Acute problem of uncertain severity | ||||
| Acute problem not readily diagnosed | ||||
| Short course periodic treatment | ||||
| Diagnostic procedures impractical as outpatient | ||||
| Children's Hospital, Buffalo | Admission from any source | 0‐21 years | Maximum 24 hours | Intensive care needs |
| Short stay elective surgery | Routine diagnostic tests | |||
| Estimated length of stay <24 hours | Holding prior to admission | |||
| Children's National, Washington, DC | Inadequate response to 3 subcutaneous epinephrine injections | 8 months to 19 years | Not reported | Not reported |
| Children's Memorial, Chicago | Asthma: | |||
| Available parentAsthma score 5Inadequate response to ED treatment | >1 year | Maximum 24 hours | Past history of BPD, CF, CHD, other debilitating disease | |
| Dehydration: | ||||
| Cases receiving oral hydration | 3‐24 months | 12 hours for oral | Intensive care need | |
| Parent preference if given IV hydration | 8 to 12 hours for IV | Hypernatremia | ||
| Minneapolis Children's | Conditions listed in Table 3 | Not reported | Maximum 10 hours | Not reported |
| Children's Hospital, Boston | Straightforward diagnoses as determined by ED staff | Not reported | Not reported | Other complex medical issues |
| Bed availability | ||||
| Connecticut Children's | PEM attending discretionLimited severity of illnessUsually confined to a single organ systemClearly identified plan of care | Not reported | After 3‐4 hours in ED Low likelihood of requiring extended care >23 hours | Asthma: no supplemental O2 need, nebulized treatments >Q2 hourCroup: no supplemental O2 need, <2 racemic epinephrine treatmentsDehydration: inability to tolerate orals, bicarbonate >10, 40 mL/kg IVFSeizure: partial or generalized, postictal, unable to tolerate oralsPoisoning: mild or no symptoms, poison control recommendation |
| Children's Hospital, Denver | Intussusception: following reduction | 0‐18 years | After 3‐4 hours in ED | Not reported |
| Dehydration: based on clinical status | ||||
| Johns Hopkins, Bayview | Consultation with on‐duty pediatrician | 0‐18 years | Minimum of 2 hours | Patients requiring subspecialty or intensive care services |
| High likelihood of discharge at 24 hours | ||||
| Children's Hospital of Philadelphia | Sole discretion of the ED attending | Not reported | Minimum 4 hours | No direct admissions |
| Single focused acute condition | Maximum 23 hours | Diagnostic dilemmas | ||
| Clinical conditions appropriate for observation | Underlying complex medical problems | |||
| Primary Children's Medical Center | Observation unit attending discretion | 0‐21 years | Minimum 3 hours | Admission holds |
| Scheduled procedures as space available | Maximum 24 hours | Intensive care needs | ||
| ED admit after consult with OU doctor | Complicated, multisystem disease | |||
| Clear patient care goals | Need for multiple specialty consults | |||
| Limited severity of illness | Psychiatric patients | |||
| Diagnostic evaluation | ||||
Ages of Children Under Observation
Seven of 11 hospitals reported the age range of patients accepted in their OU (Table 2). All but 1 unit accepted children from infants to young adults, 18 to 21 years of age.43 In the 6 units that reported the age distribution of their OU population, roughly 20% were <1 year, more than 50% were <5 years, and fewer than 30% fell into an adolescent age range.5, 6, 26, 32, 34, 43
Conditions Under Observation
Many conditions under observation were common across time and location (Table 3). The list of conditions cared for in OUs has expanded in recent years. Medical conditions predominated over surgical. While the majority of observation cases required acute care, nearly one‐half of the units accepted children with scheduled care needs (eg, routine postoperative care, procedures requiring sedation, infusions, and extended evaluations such as electroencephalograms or pH probes). These scheduled cases, cared for within the OU structure, provided more steady demand for OU services.
| King's County, Downstate Brooklyn | Children's Hospital, Buffalo | Minneapolis Children's | Children's Hospital, Boston | Connecticut Children's | Children's Hospital, Denver | Johns Hopkins, Bayview | Children's Hospital of Philadelphia | Primary Children's Medical Center, Salt Lake City | |
|---|---|---|---|---|---|---|---|---|---|
| |||||||||
| Respiratory | |||||||||
| Asthma | |||||||||
| Pneumonia | |||||||||
| Bronchiolitis | |||||||||
| Croup | |||||||||
| Allergic reaction | |||||||||
| Cardiology | |||||||||
| Gastrointestinal | |||||||||
| Vomiting | |||||||||
| Gastro/dehydration | |||||||||
| Abdominal pain | |||||||||
| Constipation | |||||||||
| Diabetes | |||||||||
| Neurologic | |||||||||
| Seizure | |||||||||
| Head injury | |||||||||
| Infection | |||||||||
| Sepsis evaluation | |||||||||
| UTI/pyelonephritis | |||||||||
| Cellulitis | |||||||||
| Fever | |||||||||
| Pharyngitis | |||||||||
| Otitis media | |||||||||
| Adenitis | |||||||||
| Ingestion/poisoning | |||||||||
| Hematologic | |||||||||
| Sickle cell disease | |||||||||
| Transfusion/emnfusion | |||||||||
| Psychological/social | |||||||||
| Dental | |||||||||
| Surgical conditions | |||||||||
| Foreign body | |||||||||
| Trauma | |||||||||
| Burn | |||||||||
| Orthopaedic injury | |||||||||
| Postoperative complication | |||||||||
| Scheduled care | |||||||||
| Diagnostic workup | |||||||||
| Procedures/sedation | |||||||||
| Elective surgery | |||||||||
Reimbursement
One publication highlighted the special billing rules that must be considered for observation care.27 In 3 studies, payers recognized cost‐savings associated with the OU's ability to provide outpatient management for cases that would traditionally require inpatient care.31, 35, 38
Observation Unit Outcomes
Outcomes reported for pediatric OU stays fall into 4 major categories: length of stay (LOS), admission rates, return visit rates, and costs. Despite these seemingly straightforward groupings, there was significant heterogeneity in reporting these outcomes.
Length of Stay
The start time for OU length of stay (LOS) is not clearly defined in the articles included in this review. While the start of an observation period is assumed to begin at the time the order for observation is placed, it is possible that the LOS reported in these publications began at the time of ED arrival or the time the patient was physically transferred to the OU. The average LOS for individual OUs ranged from 10 to 15 hours.5, 6, 26, 30, 35, 38, 40, 41, 43 One ward‐based and 1 ED‐based unit reported LOS extending beyond 24 hours,7, 30 with averages of 35 and 9 hours, respectively. Two units limited the duration of care to <10 hours.31, 38
For studies that included a comparison group, OU stays were consistently shorter than a traditional inpatient stay by 6 to 110 hours.7, 36, 38, 39, 42 No significant differences in clinical parameters between groups were reported. There was appreciable variation in the average LOS across institutions for similar conditions, 12 to 35 hours for asthma,5, 7, 34, 35 and 9 to 18 hours for dehydration.5, 34, 36, 38
Admission Rates
Rates of hospital admission after observation from the 9 OUs reporting this outcome are presented in Table 4. Three publications from a single institution counted hospital admission in the 48 to 72 hours following discharge from the OU as though the patient were admitted to the hospital directly from the index OU stay.33, 40, 41 Conditions with the lowest admission rates, <10%, included croup, neurologic conditions, ingestions, trauma, and orthopedic injuries. The highest admission rates, >50%, were for respiratory conditions including asthma, pneumonia, and bronchiolitis.
| King's County, Downstate Brooklyn (%) | Children's Hospital, Buffalo (%) | Connecticut Children's (%) | Johns Hopkins, Bayview (%) | Children's Hospital of Philadelphia (%) | Primary Children's Medical Center, Salt Lake City (%) | |
|---|---|---|---|---|---|---|
| ||||||
| Unscheduled care | 42 | 17 | 11 | 25 | 25 | 15 |
| Respiratory | 32 | |||||
| Asthma | 57 | 16 | 26 | 22 | 22‐25* | |
| Pneumonia | 50 | 23 | 30‐48 | |||
| Bronchiolitis | 46 | 32 | 43 | |||
| Croup | 9 | 17 | 9 | 4‐6 | ||
| Allergic reaction | 3 | |||||
| Cardiology | 22 | |||||
| Gastrointestinal | 43 | 19 | ||||
| Vomiting | 5 | 22 | ||||
| Gastro/dehydration | 23 | 15/21 | 16* | |||
| Abdominal pain | 9 | 17 | 27 | |||
| Constipation | 9 | |||||
| Diabetes | 17 | |||||
| Neurologic | 10 | |||||
| Seizure | 19 | 8 | 17 | 18 | ||
| Head injury | 7 | 5* | ||||
| Infection | 19 | 34 | ||||
| Sepsis evaluation | 25 | 22 | ||||
| UTI/pyelonephritis | 25 | 16 | ||||
| Cellulitis | 15 | |||||
| Fever | 16 | 26 | ||||
| Pharyngitis | 13 | |||||
| Otitis media | 21 | |||||
| Ingestion/poisoning | 9 | 4 | 4 | 9 | 10 | 5 |
| Hematologic | 23 | |||||
| Transfusion/emnfusion | 2 | |||||
| Psychological/social | 21 | 80 | 17 | |||
| Dental | 14 | |||||
| Surgical conditions | ||||||
| Foreign body | ||||||
| Trauma | 13 | 2 | 53 | 5 | ||
| Burn | 13 | |||||
| Orthopedic injury | 22 | 3 | ||||
| Postoperative complication | 26 | 16 | ||||
| Scheduled care | ||||||
| Diagnostic workup | 0‐5 | |||||
| Procedures/sedation | 0.1‐9.0 | |||||
| Elective surgery | 13 | 0‐5 | ||||
Return Visit Rates
Unscheduled return visit rates were reported in 9 publications from 6 institutions and ranged from 0.01% to 5%.7, 26, 33, 3537, 3941 Follow‐up timeframes ranged from 48 hours to 1 month. Return visits were inconsistently defined. In most studies, rates were measured in terms of ED visits.26, 33, 3537, 39, 41 One ward‐based unit counted only hospital readmissions toward return visit rates.7 Three publications, from ED‐based units, counted hospital readmissions in the 2 to 5 days following observation toward admission rates and not as return visits.33, 40, 41 In most studies, data on return visits were collected from patient logs or patient tracking systems. Three studies contacted patients by phone and counted return visits to the clinic.3537 No studies reported on adherence to scheduled visits following observation.
Costs
Seven studies reported financial benefits of OU care when compared with traditional hospital care.7, 30, 31, 35, 37, 38, 42 Two centers admitted patients to inpatient care if their observation period reached a set time limit, after which cost savings were no longer realized.31, 35 Cost savings associated with the OU treatment of asthma and dehydration were attributed to lower charges for an OU bed.35, 38 Decreased charges for the OU treatment of croup were related to shorter LOS.42
Discussion
In the 40 years since the first studies of pediatric OUs, several US health systems have extended observation services to children. This model of care may be expanding, as suggested by an increase in the number of publications in the past 10 years. However, the number of centers within the US reporting on their OU experience remains small. Our systematic review identified a recurrent theme related to OUsthe opportunity to improve operational processes of care compared with the traditional inpatient alternative. We have identified the need to standardize OU outcomes and propose measures for future OU research.
Observation Unit Operations
The OU care model expands outpatient management of acute conditions to include children who are neither ready for discharge nor clear candidates for inpatient admission. OUs have demonstrated the ability to care for patients across the pediatric age spectrum. Over the decades spanning these publications, advances in medical therapy such as antiemetics for gastroenteritis and early administration of systemic steroids for asthma may have resulted in lower admission rates or shorter time to recovery.44, 45 Despite these advances, there are marked consistencies in the conditions cared for within OUs over time. The data summarized here may help guide institutions as they consider specific pediatric conditions amenable to observation care.
The hospitals included in this review either added physical space or revised services within existing structures to establish their OU. Hospitals facing physical constraints may look to underutilized areas, such as recovery rooms, to provide observation care, as observation does not require the use of licensed inpatient beds. Several units have responded to daily fluctuations in unscheduled observation cases by also serving patients who require outpatient procedures, brief therapeutic interventions, and diagnostic testing. By caring for patients with these scheduled care needs during the day, there is a more steady flow of patients into the OU. While hospitals traditionally have used postanesthesia care units and treatment rooms for scheduled cases, OUs appear to benefit from the consistent resource allocation associated with a constant demand for services.
To date, the vast majority of pediatric OUs in the published literature have emerged as an extension of ED services. Now, with the expansion of pediatric hospitalist services and movement toward 24/7 inpatient physician coverage, there may be increased development of ward‐based OUs and the designation of inpatient observation status. While ward‐based OUs managed by pediatric hospitalists may be well established, we were not able to identify published reports on this structure of care. A national survey of health systems should be undertaken to gather information regarding the current state of pediatric observation services.
When creating policies and procedures for OUs, input should be sought from stakeholders including hospitalists, PEM providers, primary care providers, subspecialists, mid‐level providers, nurses, and ancillary staff. As patients requiring observation level of care do not neatly fit an outpatient or inpatient designation, they present an opportunity for hospitalist and PEM physician groups to collaborate.4648 Calling on the clinical experiences of inpatient and ED providers could offer unique perspectives leading to the development of innovative observation care models.
This review focused on institutions with dedicated observation services, which in all but 1 study26 consisted of a defined geographic unit. It is possible that the practices implemented in an OU could have hospital‐wide impact. For example, 1 study reported reduction in LOS for all asthma cases after opening a ward‐based unit.7 Further, pediatric hospitalist services have been associated with shorter LOS49 and increased use of observation status beds compared with traditional ward services.50 As pediatric hospitalists expand their scope of practice to include both observation and inpatient care, clinical practice may be enhanced across these care areas. It follows that the impact of observation protocols on care in the ward setting should be independently evaluated.
The costs associated with the establishment and daily operations of an OU were not addressed in the reviewed publications. Assertions that observation provides a cost‐effective alternative to inpatient care4, 7, 23, 42 should be balanced by the possibility that OUs extend care for patients who could otherwise be discharged directly home. Studies have not evaluated the cost of OU care compared with ED care alone. Research is also needed to assess variations in testing and treatment intensity in OUs compared with the ED and inpatient alternatives. Reimbursement for observation is dependent in part upon institutional contracts with payers. A full discussion of reimbursement issues around observation services is beyond the scope of this review.
Observation Unit Outcomes
Length of Stay
Although most studies reported LOS, direct comparisons across institutions are difficult given the lack of a consistently referenced start to the observation period. Without this, LOS could begin at the time of ED arrival, time of first treatment, or time of admission to the OU. Identifying and reporting the elements contributing to LOS for observation care is necessary. The time of OU admission is important for billing considerations; the time of first treatment is important to understanding the patient's response to medical interventions; the time of ED arrival is important to evaluating ED efficiency. Each of these LOS measures should be reported in future studies.
Direct comparisons of LOS are further complicated by variability in the maximum permissible duration of an OU stay, ranging from 8 to 24 hours in the included studies. Despite these limits, some OU care will extend beyond set limits due to structural bottlenecks. For example, once the inpatient setting reaches capacity, observation LOS for patients who require admission will be prolonged. The best evaluation of LOS would come from prospective study design utilizing either randomization or quality improvement methods.
Defining Success and Failure in Observation Care
In the reviewed literature, observation failures have been defined in terms of admission after observation and unscheduled return visit rates. Admission rates are heavily dependent on appropriate selection of cases for observation. Although some observation cases are expected to require inpatient admission, OUs should question the validity of their unit's acceptance guidelines if the rate of admission is >30%.51 High rates could be the result of inadequate treatment or the selection of children too sick to improve within 24 hours. Low rates could indicate overutilization of observation for children who could be discharged directly home. Full reporting on the number of children presenting with a given condition and the different disposition pathways for each is needed to evaluate the success of OUs. Condition‐specific benchmarks for admission after observation rates could guide hospitals in their continuous improvement processes.
Unscheduled return visits may reflect premature discharge from care, diagnostic errors, or development of a new illness. OU care may influence patient adherence to scheduled follow‐up care but this has not been evaluated to date. In future research, both scheduled and unscheduled return visits following ED visits, observation stays, and brief inpatient admissions for similar disease states should be reported for comparison. Standard methodology for identifying return visits should include medical record review, claims analyses, and direct patient contact.
As hospitals function at or near capacity,52, 53 it becomes important to delineate the appropriate length of time to monitor for response to treatments in a given setting. Limited capacity was a frequently cited reason for opening a pediatric OU; however, the impact of OUs on capacity has not yet been evaluated. Operations research methods could be used to model OU services' potential to expand hospital capacity. This research could be guided by evaluation of administrative data from across institutions to identify current best practices for pediatric OU and observation status care.
OU benchmarking in the United States has begun with a small number of adult units participating in the ED OU Benchmark Alliance (EDOBA).54 In Table 5, we propose dashboard measures for pediatric OU continuous quality improvement. The proposed measures emphasize the role of observation along the continuum of care for acute conditions, from the ED through the OU with or without an inpatient stay to clinic follow‐up. Depending on the structure of observation services, individual institutions may select to monitor different dashboard measures from the proposed list. Patient safety and quality of care measures for the conditions commonly receiving pediatric OU care should also be developed.
| ED |
OU |
Inpatient |
Clinic | |
|---|---|---|---|---|
| ||||
| Length of stay* | ED arrival to OU admission | OU admit to disposition | Inpatient admit to discharge | |
| ED arrival to discharge home from OU | ||||
| ED arrival to discharge from inpatient following OU care | ||||
| OU admission to discharge home from inpatient care | ||||
| Admission* | % ED census admitted inpatient | % OU census admitted | ||
| % ED census that is observed | ||||
| Unscheduled return visits* | To ED | Requiring OU admission | Requiring inpatient admission | |
| Scheduled follow‐up* | To ED | To primary care or subspecialist office | ||
| Capacity | ED crowding scales | Unable to accept transfers | ||
| ED left before evaluation rates | Inpatient occupancy | |||
| Ambulance diversion | ||||
| Satisfaction | Patient/Parent | |||
| ED providers | OU providers | Inpatient providers | Follow‐up providers | |
| Cost | ED care | OU care | Inpatient care | |
| Total encounter | ||||
Limitations
The most important limitations to this review are the heterogeneity in interventions and reporting of outcomes, which precluded our ability to combine data or conduct meta‐analyses. We attempted to organize the outcomes data into clear and consistent groupings. However, we could not compare the performance of 1 center with another due to differences in OU structure, function, and design.
In order to focus this systematic review, we chose to include only peer reviewed publications that describe pediatric OUs within the United States. This excludes expert guidelines, which may be of value to institutions developing observation services.
Our search found only a small number of centers that utilize OUs and have published their experience. Thus, our review is likely subject to publication bias. Along this line, we identified 9 additional publications where children were cared for alongside adults within a general OU.5563 This suggests an unmeasured group of children under observation in general EDs, where more than 90% of US children receive acute care.64 These articles were excluded because we were unable to distinguish pediatric specific outcomes from the larger study population.
Finally, retrospective study design is subject to information bias. Without a comparable control group, it is difficult to understand the effects of OUs. Patients directly admitted or discharged from the ED and patients who require admission after observation all differ from patients discharged from observation in ways that should be controlled for with a randomized study design.
Conclusions
OUs have emerged to provide treatment at the intersection of outpatient and inpatient care during a time of dramatic change in both emergency and hospital medicine. As hospitalists expand their scope of practice to include observation care, opportunities will arise to collaborate with ED physicians and share their growing expertise in quality and efficiency of hospital care delivery to improve observation services for children. OUs have been established with laudable goalsto reduce inpatient admissions, increase patient safety, improve efficiency, and control costs. The current evidence is not adequate to determine if this model of healthcare delivery achieves these goals for children. Through synthesis of existing data, we have identified a need for standard reporting for OU outcomes and propose consistent measures for future observation care research. Only through prospective evaluation of comparable outcomes can we appraise the performance of pediatric OUs across institutions.
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- ,,.The pediatric hybrid observation unit: an analysis of 6477 consecutive patient encounters.Pediatrics.2005;115(5):e535–e542.
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- ,,, et al.Impact of a short stay unit on asthma patients admitted to a tertiary pediatric hospital.Qual Manag Health Care.1997;6(1):14–22.
- ,,, et al.Management of observation units. American College of Emergency Physicians.Ann Emerg Med.1995;25(6):823–830.
- ,,, et al. The observation unit: an operational overview for the hospitalist. Society of Hospital Medicine White Paper 2009; Available at: http://www.hospitalmedicine.org/Content/NavigationMenu/Publications/WhitePapers/White_Papers.htm. Accessed July2009.
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- ,,, et al.Emergency department observation unit versus hospital inpatient care for a chronic asthmatic population: a randomized trial of health status outcome and cost.Med Care.1998;36(4):599–609.
- ,,, et al.Costs of an emergency department‐based accelerated diagnostic protocol vs hospitalization in patients with chest pain: a randomized controlled trial.JAMA.1997;278(20):1670–1676.
- .Management of patients with infectious diseases in an emergency department observation unit.Emerg Med Clin North Am.2001;19(1):187–207.
- ,,, et al.A comparison between emergency diagnostic and treatment unit and inpatient care in the management of acute asthma.Arch Intern Med.1997;157(18):2055–2062.
- .Chest pain observation units.Emerg Med J.2001;18(2):148.
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- ,,, et al.A cooperative care model: cardiologists and hospitalists reduce length of stay in a chest pain observation. In:5th Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke, Washington, DC, May 15‐17, 2003.Philadelphia, PA:Lippincott Williams 2003. p.P186.
- ,.Observation unit management of pediatric emergencies.Emerg Med Clin North Am.1991;9(3):669–676.
- .A short stay or 23‐hour ward in a general and academic children's hospital: are they effective?Pediatr Emerg Care.2000;16(4):223–229.
- ,,, et al.Trends in high turnover stays among children hospitalized in the United States, 1993 through 2003.Pediatrics.2009;123:996–1002.
- .Hospital based alternatives to acute paediatric admission: a systematic review.Arch Dis Child.2005;90(2):138–142.
- ,,.Short‐stay units and observation medicine: a systematic review.Med J Aust.2003;178(11):559–563.
- ,,.Use of emergency observation and assessment wards: a systematic literature review.Emerg Med J.2003;20(2):138–142.
- Oxford Centre for Evidence‐Based Medicine. Levels of evidence and grades of recommendation (May 2001). Available at: http://www.cebm.net/levels_of_evidence.asp. Accessed July2009.
- ,,, et al.Pediatric observation status beds on an inpatient unit: an integrated care model.Pediatr Emerg Care.2004;20(1):17–21.
- .Pediatric update. Our new rapid treatment unit: an innovative adaptation of the “less than 24‐hour stay” holding unit.J Emerg Nurs.2000;26(5):507.
- ,,.Use of an observation unit by a pediatric emergency department for common pediatric illnesses.Pediatr Emerg Care.2001;17(5):321–323.
- ,,, et al.Observation medicine: the expanded role of the nurse practitioner in a pediatric emergency department extended care unit.Pediatr Emerg Care.2005;21(3):199–202.
- ,,.An observation unit in a pediatric emergency department: one children's hospital's experience.J Emerg Nurs.2002;28(5):407–413.
- ,,.When the patient requires observation not hospitalization.J Nurs Admin.1988;18(10):20–23.
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- ,,.Usefulness of the serum electrolyte panel in the management of pediatric dehydration treated with intravenously administered fluids.Pediatrics.2004;114(5):1227–1234.
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- ,,.A reduction in hospitalization, length of stay, and hospital charges for croup with the institution of a pediatric observation unit.Am J Emerg Med.2006;24(7):818–821.
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The first observation units were implemented more than 40 years ago with the goal of reducing the number and duration of inpatient stays. Since then, observation units (OUs) have evolved as a safe alternative to hospitalization14 for the delivery of finite periods of care, typically less than 24 hours.58 Observation services allow for time to determine the need for hospitalization in cases that are unclear after their initial evaluation and treatment.9 Observation status is an administrative classification related to reimbursement that can be applied to patients whose diagnosis, treatment, stabilization, and discharge can reasonably be expected within 24 hours.10, 11 The site of care for observation is dependent in part upon existing facility structures; some institutions utilize virtual OUs within the emergency department (ED) or hospital ward, while others have dedicated, geographically distinct OUs, which may function as an extension of either the ED or inpatient settings.9
OUs have been instrumental in providing care to adult patients with chest pain, asthma, and acute infections.1218 Recently, there has been an increase in the number of publications from pediatric OUs in the United States and abroad. Observation may be a preferred model of care for select pediatric patients, as hospitalized children often experience brief stays.1921 Previous reviews on this model of care have combined adult and pediatric literature and have included research from countries with healthcare structures that differ considerably from the United States.2224 To date, no systematic review has summarized the pediatric OU literature with a focus on the US healthcare system.
As payers and hospitals seek cost‐effective alternatives to traditional inpatient care, geographically distinct OUs may become integral to the future of healthcare delivery for children. This systematic review provides a descriptive overview of the structure and function of pediatric OUs in the United States. We also scrutinize the outcome measures presented in the included publications and propose future directions for research to improve both observation unit care, as well as the care delivered to patients under observation status within general inpatient or ED settings.
Methods
Literature Search
With the assistance of a health services librarian, a search of the following electronic databases from January 1, 1950 through February 5, 2009 was conducted: 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. Key words used for the Boolean search are included in Appendix A. In addition, we conducted a manual search of reference lists from reviews, guidelines, and articles meeting inclusion criteria.
We included English language peer‐reviewed publications that reported on pediatric OU care in the United States. Studies were included if they reported outcomes including lengths of stay, admission from observation rates, return visit rates, costs or charges. Descriptive publications of pediatric OU structure and function were also included. Studies were excluded if they were conducted outside the United States, evaluated psychiatric or intensive care, reported on observation status in an ED without an OU or observation status on a traditional inpatient ward. Two reviewers (M.M. and C.K.) identified articles for inclusion. Any disagreements between the reviewers were resolved by discussion and consensus agreement. Interrater reliability was assessed using the kappa statistic.
Quality Assessment
The quality of each study was rated using the Oxford Centre for Evidence‐based Medicine levels of evidence.25 With this system, levels of evidence range from 1a (homogeneous systematic review of randomized, controlled trials) to 5 (expert opinion without explicit critical appraisal).
Data Synthesis
Data on study design, OU characteristics, patient populations, and outcomes were extracted using a standardized form. Heterogeneity of study design, interventions, and outcomes precluded the ability to conduct meta‐analyses.
Results
A systematic search of the electronic databases identified 222 unique citations (Figure 1). A total of 107 abstracts were evaluated. We identified 48 articles for full‐text review, of which 18 met inclusion criteria. Hand search of references yielded 24 additional articles, of which 3 met inclusion criteria. Interrater agreement for selected articles was high at 98% (kappa = 0.85).
Observation Unit Characteristics
The majority of research on OUs has been conducted at large academic pediatric centers. One publication was from a community hospital.26 These studies present data on more than 22,000 children cared for in OUs of 11 hospitals over a 32‐year time span. Most studies were level 2 evidence: 2b, retrospective cohort studies and low‐quality randomized, controlled trials; or 2c, outcomes research. Three were descriptive and not assigned a formal evidence level.2729
Table 1 highlights general features of U.S. pediatric OUs. Five institutions renovated or expanded clinical space in order to open the OU.27, 2932 Units ranged in size from 3 to 23 beds. The OU was located in or near the ED in all but 2 hospitals, which had ward‐based units. The ED was the primary entry point into the OU with only 2 open model units accepting patients from other settings.5, 32 The annual number of observation cases ranged from 1000 to 3000 in children's hospitals. Approximately 500 ward‐based observation cases per year were cared for in the single community hospital studied. Three reports included time trends showing increased OU utilization over study years.5, 30, 31
| Publication (Year); Condition | Study Design; Level of Evidence; Time Frame; Sample Size | Hospital; Observation Setting; Year Opened | Site | Beds | Entry Point | Staffing; Physicians; Nurses |
|---|---|---|---|---|---|---|
| ||||||
| Gururaj et al.43 (1972); all conditions | Retrospective cohort; 2c; 1 year; 437 cases under observation | King's County Downstate Brooklyn; short‐stay unit | ED | 3 | Not reported | Pediatric residents; general pediatricians |
| Ellerstein and Sullivan,32 (1980); all conditions | Retrospective cohort; 2c; 6 years; 5858 cases of unscheduled care plus 1403 elective surgery cases | Children's Hospital Buffalo; observation unit; 1972 | ED | 8 | ED, clinic, procedure/OR | Primary care pediatricians; other specialists; pediatric residents |
| O'Brien et al.37 (1980); asthma | Retrospective cohort; 2c; 1 month; 434 cases of asthma, 328 discharged directly from ED, 106 treated in holding unit | Children's National DC; holding unit | ED | 6 | ED | 1‐2 pediatric residents; 1‐2 nurses |
| Willert et al.35 (1985); asthma | Randomized*; 2b; 578 cases of asthma; 166 cases 1.5 hours postaminophylline, 103 randomized, 52 to holding unit | Children's Memorial Chicago; holding room | ED | 5 | ED | General pediatricians; pediatric residents; PEM nurses |
| Listernick et al.38 (1986); dehydration | Randomized; 2b; 29 cases of dehydration; 22 to holding unit | Children's Memorial Chicago | ||||
| Balik et al.31 (1988); all conditions | Descriptive; none given | Minneapolis Children's; short‐stay unit observation area; 1985 | Day surgery area adjacent to ED | Not reported | Not reported | General pediatricians; pediatric nurses (shared with ED) |
| Marks et al.7 (1997); all conditions | Retrospective cohort; 2c; 5 months; 968 cases in short‐stay unit | Children's Hospital Boston; short‐stay unit; 1994 | Ward | 4‐18 | ED | Primary care pediatricians; PEM physicians; pediatric residents; pediatric nurses; 1:6 nurse:patient ratio |
| Marks et al.7 (1997); asthma | Pre‐post; 2b; 400 cases of asthma; 102 pre/298 post short‐stay unit | Children's Hospital Boston | ||||
| Wiley et al.6 (1998); all conditions | Retrospective cohort; 2c; 1 year; 805 cases of unscheduled observation; plus 595 scheduled cases | Connecticut Children's; outpatient extended treatment site | ED | 10 | Not reported | PEM physicians; other specialists; 1:5 nurse:patient ratio |
| Scribano et al.65 (2001); all conditions | Retrospective cohort; 2b; 2 years; 1798 cases under observation | Connecticut Children's | ||||
| Leduc et al.30 (2002); all conditions | Retrospective cohort; 2c; 6 months; 686 cases under observation (4.8% of ED visits) | Children's Hospital Denver; OU | ED | 6 | Not reported | Not reported |
| Bajaj and Roback,30 (2003); intussusception | Retrospective cohort; 2b; 4.5 years; 78 cases of intussusception (51 under observation) | Children's Hospital Denver | ||||
| Wathen et al.36 (2004); dehydration | Convenience sample; 2c; 10 months; 182 cases of dehydration (48 under observation) | Children's Hospital Denver | ||||
| Crocetti et al.26 (2004); all conditions | Retrospective cohort; 2b; 2 years; 956 cases under observation | John Hopkin's Bayview; observation status beds; 1997 | Ward | Not reported | 99% ED 1% other location | General pediatricians covering ED and ward |
| Silvestri et al.29 (2005); all conditions | Descriptive; none given | Children's Hospital of Philadelphia; OU; 1999 | ED | 12 | ED | PEM physicians; PEM fellows; urgent care pediatricians; ED nurse practitioner; inpatient nurses |
| Alpern et al.34 (2008); all conditions | Prospective cohort; 1b; 30 months; 4453 cases under observation | Children's Hospital of Philadelphia | ||||
| Thomas27 (2000); all conditions | Descriptive; none given | Primary Children's Medical Center; RTU; 1999 | ED | 22‐26 | ED, clinic, procedure/OR | PEM physicians; general pediatricians; other specialists; no residents |
| Zebrack et al.25 (2005); all conditions | Retrospective cohort; 2b; 2 years; 4189 cases of unscheduled observation plus 2288 scheduled cases | Primary Children's Medical Center | PEM nurses; 1:4 nurse:patient ratio | |||
| Miescier et al.40 (2005); asthma | Retrospective cohort; 2b; 2 years; 3029 asthma visits; 384 admitted, 301 observed, 161cases met inclusion | Primary Children's Medical Center | ||||
| Holsti et al.41 (2005); head injury | Retrospective cohort; 2b; 2 years; 827 CHI visits, 273 admitted, 285 observed, 284 cases met inclusion | Primary Children's Medical Center | ||||
| Greenberg et al.42 (2006); croup | Retrospective pre‐post; 2b; 1 year each; 694 croup cases pre‐RTU, 66 admitted; 789 croup cases post‐RTU, 33 admitted; 76 observed | Primary Children's Medical Center | ||||
| Mallory et al.33 (2006); dehydration | Retrospective cohort; 2b; 1 year; 430 dehydration cases under observation | Primary Children's Medical Center | ||||
Staffing and Workflow
Staffing models varied and have undergone transitions over time. Prior to 1997, general pediatricians primarily provided physician services. In more recent years, OUs have utilized pediatric emergency medicine (PEM) providers. Three of the 11 units allowed for direct patient care by subspecialists.5, 6, 32 One OU was staffed by nurse practitioners.29 OU nursing backgrounds included pediatrics, emergency medicine, or PEM.
Five institutions assembled multidisciplinary teams to define the unit's role and establish policies and procedures.7, 27, 2931 Workflow in the OU focused on optimizing efficiency through standardized orders, condition‐specific treatment protocols, and bedside charting.7, 26, 33 Several units emphasized the importance of ongoing evaluations by attending physicians who could immediately respond to patient needs. Rounds occurred as often as every 4 hours.5, 7 Two centers utilized combined physician‐nursing rounds to enhance provider communication.7, 34 No publications reported on patient transitions between sites of care or at shift changes.
Criteria for Observation
All 11 hospitals have developed protocols to guide OU admissions (Table 2). Nine publications from 4 OUs commented on treatments delivered prior to observation.33, 3542 The most commonly cited criteria for admission was approval by the unit's supervising physician. Utilization review was not mentioned as an element in the OU admission decision. Common OU exclusions were the need for intensive care or monitoring while awaiting an inpatient bed; however, these were not universal. Eight centers placed bounds around the duration of OU stays, with minimum stays of 2 hours and maximum stays of 8 to 24 hours.
| Hospital | Entry Criteria | Age Range | Time | Exclusion Criteria |
|---|---|---|---|---|
| ||||
| King's County, Downstate Brooklyn | Otherwise required inpatient admission | 0‐13 years | Maximum 24 hours | Not reported |
| Acute problem of uncertain severity | ||||
| Acute problem not readily diagnosed | ||||
| Short course periodic treatment | ||||
| Diagnostic procedures impractical as outpatient | ||||
| Children's Hospital, Buffalo | Admission from any source | 0‐21 years | Maximum 24 hours | Intensive care needs |
| Short stay elective surgery | Routine diagnostic tests | |||
| Estimated length of stay <24 hours | Holding prior to admission | |||
| Children's National, Washington, DC | Inadequate response to 3 subcutaneous epinephrine injections | 8 months to 19 years | Not reported | Not reported |
| Children's Memorial, Chicago | Asthma: | |||
| Available parentAsthma score 5Inadequate response to ED treatment | >1 year | Maximum 24 hours | Past history of BPD, CF, CHD, other debilitating disease | |
| Dehydration: | ||||
| Cases receiving oral hydration | 3‐24 months | 12 hours for oral | Intensive care need | |
| Parent preference if given IV hydration | 8 to 12 hours for IV | Hypernatremia | ||
| Minneapolis Children's | Conditions listed in Table 3 | Not reported | Maximum 10 hours | Not reported |
| Children's Hospital, Boston | Straightforward diagnoses as determined by ED staff | Not reported | Not reported | Other complex medical issues |
| Bed availability | ||||
| Connecticut Children's | PEM attending discretionLimited severity of illnessUsually confined to a single organ systemClearly identified plan of care | Not reported | After 3‐4 hours in ED Low likelihood of requiring extended care >23 hours | Asthma: no supplemental O2 need, nebulized treatments >Q2 hourCroup: no supplemental O2 need, <2 racemic epinephrine treatmentsDehydration: inability to tolerate orals, bicarbonate >10, 40 mL/kg IVFSeizure: partial or generalized, postictal, unable to tolerate oralsPoisoning: mild or no symptoms, poison control recommendation |
| Children's Hospital, Denver | Intussusception: following reduction | 0‐18 years | After 3‐4 hours in ED | Not reported |
| Dehydration: based on clinical status | ||||
| Johns Hopkins, Bayview | Consultation with on‐duty pediatrician | 0‐18 years | Minimum of 2 hours | Patients requiring subspecialty or intensive care services |
| High likelihood of discharge at 24 hours | ||||
| Children's Hospital of Philadelphia | Sole discretion of the ED attending | Not reported | Minimum 4 hours | No direct admissions |
| Single focused acute condition | Maximum 23 hours | Diagnostic dilemmas | ||
| Clinical conditions appropriate for observation | Underlying complex medical problems | |||
| Primary Children's Medical Center | Observation unit attending discretion | 0‐21 years | Minimum 3 hours | Admission holds |
| Scheduled procedures as space available | Maximum 24 hours | Intensive care needs | ||
| ED admit after consult with OU doctor | Complicated, multisystem disease | |||
| Clear patient care goals | Need for multiple specialty consults | |||
| Limited severity of illness | Psychiatric patients | |||
| Diagnostic evaluation | ||||
Ages of Children Under Observation
Seven of 11 hospitals reported the age range of patients accepted in their OU (Table 2). All but 1 unit accepted children from infants to young adults, 18 to 21 years of age.43 In the 6 units that reported the age distribution of their OU population, roughly 20% were <1 year, more than 50% were <5 years, and fewer than 30% fell into an adolescent age range.5, 6, 26, 32, 34, 43
Conditions Under Observation
Many conditions under observation were common across time and location (Table 3). The list of conditions cared for in OUs has expanded in recent years. Medical conditions predominated over surgical. While the majority of observation cases required acute care, nearly one‐half of the units accepted children with scheduled care needs (eg, routine postoperative care, procedures requiring sedation, infusions, and extended evaluations such as electroencephalograms or pH probes). These scheduled cases, cared for within the OU structure, provided more steady demand for OU services.
| King's County, Downstate Brooklyn | Children's Hospital, Buffalo | Minneapolis Children's | Children's Hospital, Boston | Connecticut Children's | Children's Hospital, Denver | Johns Hopkins, Bayview | Children's Hospital of Philadelphia | Primary Children's Medical Center, Salt Lake City | |
|---|---|---|---|---|---|---|---|---|---|
| |||||||||
| Respiratory | |||||||||
| Asthma | |||||||||
| Pneumonia | |||||||||
| Bronchiolitis | |||||||||
| Croup | |||||||||
| Allergic reaction | |||||||||
| Cardiology | |||||||||
| Gastrointestinal | |||||||||
| Vomiting | |||||||||
| Gastro/dehydration | |||||||||
| Abdominal pain | |||||||||
| Constipation | |||||||||
| Diabetes | |||||||||
| Neurologic | |||||||||
| Seizure | |||||||||
| Head injury | |||||||||
| Infection | |||||||||
| Sepsis evaluation | |||||||||
| UTI/pyelonephritis | |||||||||
| Cellulitis | |||||||||
| Fever | |||||||||
| Pharyngitis | |||||||||
| Otitis media | |||||||||
| Adenitis | |||||||||
| Ingestion/poisoning | |||||||||
| Hematologic | |||||||||
| Sickle cell disease | |||||||||
| Transfusion/emnfusion | |||||||||
| Psychological/social | |||||||||
| Dental | |||||||||
| Surgical conditions | |||||||||
| Foreign body | |||||||||
| Trauma | |||||||||
| Burn | |||||||||
| Orthopaedic injury | |||||||||
| Postoperative complication | |||||||||
| Scheduled care | |||||||||
| Diagnostic workup | |||||||||
| Procedures/sedation | |||||||||
| Elective surgery | |||||||||
Reimbursement
One publication highlighted the special billing rules that must be considered for observation care.27 In 3 studies, payers recognized cost‐savings associated with the OU's ability to provide outpatient management for cases that would traditionally require inpatient care.31, 35, 38
Observation Unit Outcomes
Outcomes reported for pediatric OU stays fall into 4 major categories: length of stay (LOS), admission rates, return visit rates, and costs. Despite these seemingly straightforward groupings, there was significant heterogeneity in reporting these outcomes.
Length of Stay
The start time for OU length of stay (LOS) is not clearly defined in the articles included in this review. While the start of an observation period is assumed to begin at the time the order for observation is placed, it is possible that the LOS reported in these publications began at the time of ED arrival or the time the patient was physically transferred to the OU. The average LOS for individual OUs ranged from 10 to 15 hours.5, 6, 26, 30, 35, 38, 40, 41, 43 One ward‐based and 1 ED‐based unit reported LOS extending beyond 24 hours,7, 30 with averages of 35 and 9 hours, respectively. Two units limited the duration of care to <10 hours.31, 38
For studies that included a comparison group, OU stays were consistently shorter than a traditional inpatient stay by 6 to 110 hours.7, 36, 38, 39, 42 No significant differences in clinical parameters between groups were reported. There was appreciable variation in the average LOS across institutions for similar conditions, 12 to 35 hours for asthma,5, 7, 34, 35 and 9 to 18 hours for dehydration.5, 34, 36, 38
Admission Rates
Rates of hospital admission after observation from the 9 OUs reporting this outcome are presented in Table 4. Three publications from a single institution counted hospital admission in the 48 to 72 hours following discharge from the OU as though the patient were admitted to the hospital directly from the index OU stay.33, 40, 41 Conditions with the lowest admission rates, <10%, included croup, neurologic conditions, ingestions, trauma, and orthopedic injuries. The highest admission rates, >50%, were for respiratory conditions including asthma, pneumonia, and bronchiolitis.
| King's County, Downstate Brooklyn (%) | Children's Hospital, Buffalo (%) | Connecticut Children's (%) | Johns Hopkins, Bayview (%) | Children's Hospital of Philadelphia (%) | Primary Children's Medical Center, Salt Lake City (%) | |
|---|---|---|---|---|---|---|
| ||||||
| Unscheduled care | 42 | 17 | 11 | 25 | 25 | 15 |
| Respiratory | 32 | |||||
| Asthma | 57 | 16 | 26 | 22 | 22‐25* | |
| Pneumonia | 50 | 23 | 30‐48 | |||
| Bronchiolitis | 46 | 32 | 43 | |||
| Croup | 9 | 17 | 9 | 4‐6 | ||
| Allergic reaction | 3 | |||||
| Cardiology | 22 | |||||
| Gastrointestinal | 43 | 19 | ||||
| Vomiting | 5 | 22 | ||||
| Gastro/dehydration | 23 | 15/21 | 16* | |||
| Abdominal pain | 9 | 17 | 27 | |||
| Constipation | 9 | |||||
| Diabetes | 17 | |||||
| Neurologic | 10 | |||||
| Seizure | 19 | 8 | 17 | 18 | ||
| Head injury | 7 | 5* | ||||
| Infection | 19 | 34 | ||||
| Sepsis evaluation | 25 | 22 | ||||
| UTI/pyelonephritis | 25 | 16 | ||||
| Cellulitis | 15 | |||||
| Fever | 16 | 26 | ||||
| Pharyngitis | 13 | |||||
| Otitis media | 21 | |||||
| Ingestion/poisoning | 9 | 4 | 4 | 9 | 10 | 5 |
| Hematologic | 23 | |||||
| Transfusion/emnfusion | 2 | |||||
| Psychological/social | 21 | 80 | 17 | |||
| Dental | 14 | |||||
| Surgical conditions | ||||||
| Foreign body | ||||||
| Trauma | 13 | 2 | 53 | 5 | ||
| Burn | 13 | |||||
| Orthopedic injury | 22 | 3 | ||||
| Postoperative complication | 26 | 16 | ||||
| Scheduled care | ||||||
| Diagnostic workup | 0‐5 | |||||
| Procedures/sedation | 0.1‐9.0 | |||||
| Elective surgery | 13 | 0‐5 | ||||
Return Visit Rates
Unscheduled return visit rates were reported in 9 publications from 6 institutions and ranged from 0.01% to 5%.7, 26, 33, 3537, 3941 Follow‐up timeframes ranged from 48 hours to 1 month. Return visits were inconsistently defined. In most studies, rates were measured in terms of ED visits.26, 33, 3537, 39, 41 One ward‐based unit counted only hospital readmissions toward return visit rates.7 Three publications, from ED‐based units, counted hospital readmissions in the 2 to 5 days following observation toward admission rates and not as return visits.33, 40, 41 In most studies, data on return visits were collected from patient logs or patient tracking systems. Three studies contacted patients by phone and counted return visits to the clinic.3537 No studies reported on adherence to scheduled visits following observation.
Costs
Seven studies reported financial benefits of OU care when compared with traditional hospital care.7, 30, 31, 35, 37, 38, 42 Two centers admitted patients to inpatient care if their observation period reached a set time limit, after which cost savings were no longer realized.31, 35 Cost savings associated with the OU treatment of asthma and dehydration were attributed to lower charges for an OU bed.35, 38 Decreased charges for the OU treatment of croup were related to shorter LOS.42
Discussion
In the 40 years since the first studies of pediatric OUs, several US health systems have extended observation services to children. This model of care may be expanding, as suggested by an increase in the number of publications in the past 10 years. However, the number of centers within the US reporting on their OU experience remains small. Our systematic review identified a recurrent theme related to OUsthe opportunity to improve operational processes of care compared with the traditional inpatient alternative. We have identified the need to standardize OU outcomes and propose measures for future OU research.
Observation Unit Operations
The OU care model expands outpatient management of acute conditions to include children who are neither ready for discharge nor clear candidates for inpatient admission. OUs have demonstrated the ability to care for patients across the pediatric age spectrum. Over the decades spanning these publications, advances in medical therapy such as antiemetics for gastroenteritis and early administration of systemic steroids for asthma may have resulted in lower admission rates or shorter time to recovery.44, 45 Despite these advances, there are marked consistencies in the conditions cared for within OUs over time. The data summarized here may help guide institutions as they consider specific pediatric conditions amenable to observation care.
The hospitals included in this review either added physical space or revised services within existing structures to establish their OU. Hospitals facing physical constraints may look to underutilized areas, such as recovery rooms, to provide observation care, as observation does not require the use of licensed inpatient beds. Several units have responded to daily fluctuations in unscheduled observation cases by also serving patients who require outpatient procedures, brief therapeutic interventions, and diagnostic testing. By caring for patients with these scheduled care needs during the day, there is a more steady flow of patients into the OU. While hospitals traditionally have used postanesthesia care units and treatment rooms for scheduled cases, OUs appear to benefit from the consistent resource allocation associated with a constant demand for services.
To date, the vast majority of pediatric OUs in the published literature have emerged as an extension of ED services. Now, with the expansion of pediatric hospitalist services and movement toward 24/7 inpatient physician coverage, there may be increased development of ward‐based OUs and the designation of inpatient observation status. While ward‐based OUs managed by pediatric hospitalists may be well established, we were not able to identify published reports on this structure of care. A national survey of health systems should be undertaken to gather information regarding the current state of pediatric observation services.
When creating policies and procedures for OUs, input should be sought from stakeholders including hospitalists, PEM providers, primary care providers, subspecialists, mid‐level providers, nurses, and ancillary staff. As patients requiring observation level of care do not neatly fit an outpatient or inpatient designation, they present an opportunity for hospitalist and PEM physician groups to collaborate.4648 Calling on the clinical experiences of inpatient and ED providers could offer unique perspectives leading to the development of innovative observation care models.
This review focused on institutions with dedicated observation services, which in all but 1 study26 consisted of a defined geographic unit. It is possible that the practices implemented in an OU could have hospital‐wide impact. For example, 1 study reported reduction in LOS for all asthma cases after opening a ward‐based unit.7 Further, pediatric hospitalist services have been associated with shorter LOS49 and increased use of observation status beds compared with traditional ward services.50 As pediatric hospitalists expand their scope of practice to include both observation and inpatient care, clinical practice may be enhanced across these care areas. It follows that the impact of observation protocols on care in the ward setting should be independently evaluated.
The costs associated with the establishment and daily operations of an OU were not addressed in the reviewed publications. Assertions that observation provides a cost‐effective alternative to inpatient care4, 7, 23, 42 should be balanced by the possibility that OUs extend care for patients who could otherwise be discharged directly home. Studies have not evaluated the cost of OU care compared with ED care alone. Research is also needed to assess variations in testing and treatment intensity in OUs compared with the ED and inpatient alternatives. Reimbursement for observation is dependent in part upon institutional contracts with payers. A full discussion of reimbursement issues around observation services is beyond the scope of this review.
Observation Unit Outcomes
Length of Stay
Although most studies reported LOS, direct comparisons across institutions are difficult given the lack of a consistently referenced start to the observation period. Without this, LOS could begin at the time of ED arrival, time of first treatment, or time of admission to the OU. Identifying and reporting the elements contributing to LOS for observation care is necessary. The time of OU admission is important for billing considerations; the time of first treatment is important to understanding the patient's response to medical interventions; the time of ED arrival is important to evaluating ED efficiency. Each of these LOS measures should be reported in future studies.
Direct comparisons of LOS are further complicated by variability in the maximum permissible duration of an OU stay, ranging from 8 to 24 hours in the included studies. Despite these limits, some OU care will extend beyond set limits due to structural bottlenecks. For example, once the inpatient setting reaches capacity, observation LOS for patients who require admission will be prolonged. The best evaluation of LOS would come from prospective study design utilizing either randomization or quality improvement methods.
Defining Success and Failure in Observation Care
In the reviewed literature, observation failures have been defined in terms of admission after observation and unscheduled return visit rates. Admission rates are heavily dependent on appropriate selection of cases for observation. Although some observation cases are expected to require inpatient admission, OUs should question the validity of their unit's acceptance guidelines if the rate of admission is >30%.51 High rates could be the result of inadequate treatment or the selection of children too sick to improve within 24 hours. Low rates could indicate overutilization of observation for children who could be discharged directly home. Full reporting on the number of children presenting with a given condition and the different disposition pathways for each is needed to evaluate the success of OUs. Condition‐specific benchmarks for admission after observation rates could guide hospitals in their continuous improvement processes.
Unscheduled return visits may reflect premature discharge from care, diagnostic errors, or development of a new illness. OU care may influence patient adherence to scheduled follow‐up care but this has not been evaluated to date. In future research, both scheduled and unscheduled return visits following ED visits, observation stays, and brief inpatient admissions for similar disease states should be reported for comparison. Standard methodology for identifying return visits should include medical record review, claims analyses, and direct patient contact.
As hospitals function at or near capacity,52, 53 it becomes important to delineate the appropriate length of time to monitor for response to treatments in a given setting. Limited capacity was a frequently cited reason for opening a pediatric OU; however, the impact of OUs on capacity has not yet been evaluated. Operations research methods could be used to model OU services' potential to expand hospital capacity. This research could be guided by evaluation of administrative data from across institutions to identify current best practices for pediatric OU and observation status care.
OU benchmarking in the United States has begun with a small number of adult units participating in the ED OU Benchmark Alliance (EDOBA).54 In Table 5, we propose dashboard measures for pediatric OU continuous quality improvement. The proposed measures emphasize the role of observation along the continuum of care for acute conditions, from the ED through the OU with or without an inpatient stay to clinic follow‐up. Depending on the structure of observation services, individual institutions may select to monitor different dashboard measures from the proposed list. Patient safety and quality of care measures for the conditions commonly receiving pediatric OU care should also be developed.
| ED |
OU |
Inpatient |
Clinic | |
|---|---|---|---|---|
| ||||
| Length of stay* | ED arrival to OU admission | OU admit to disposition | Inpatient admit to discharge | |
| ED arrival to discharge home from OU | ||||
| ED arrival to discharge from inpatient following OU care | ||||
| OU admission to discharge home from inpatient care | ||||
| Admission* | % ED census admitted inpatient | % OU census admitted | ||
| % ED census that is observed | ||||
| Unscheduled return visits* | To ED | Requiring OU admission | Requiring inpatient admission | |
| Scheduled follow‐up* | To ED | To primary care or subspecialist office | ||
| Capacity | ED crowding scales | Unable to accept transfers | ||
| ED left before evaluation rates | Inpatient occupancy | |||
| Ambulance diversion | ||||
| Satisfaction | Patient/Parent | |||
| ED providers | OU providers | Inpatient providers | Follow‐up providers | |
| Cost | ED care | OU care | Inpatient care | |
| Total encounter | ||||
Limitations
The most important limitations to this review are the heterogeneity in interventions and reporting of outcomes, which precluded our ability to combine data or conduct meta‐analyses. We attempted to organize the outcomes data into clear and consistent groupings. However, we could not compare the performance of 1 center with another due to differences in OU structure, function, and design.
In order to focus this systematic review, we chose to include only peer reviewed publications that describe pediatric OUs within the United States. This excludes expert guidelines, which may be of value to institutions developing observation services.
Our search found only a small number of centers that utilize OUs and have published their experience. Thus, our review is likely subject to publication bias. Along this line, we identified 9 additional publications where children were cared for alongside adults within a general OU.5563 This suggests an unmeasured group of children under observation in general EDs, where more than 90% of US children receive acute care.64 These articles were excluded because we were unable to distinguish pediatric specific outcomes from the larger study population.
Finally, retrospective study design is subject to information bias. Without a comparable control group, it is difficult to understand the effects of OUs. Patients directly admitted or discharged from the ED and patients who require admission after observation all differ from patients discharged from observation in ways that should be controlled for with a randomized study design.
Conclusions
OUs have emerged to provide treatment at the intersection of outpatient and inpatient care during a time of dramatic change in both emergency and hospital medicine. As hospitalists expand their scope of practice to include observation care, opportunities will arise to collaborate with ED physicians and share their growing expertise in quality and efficiency of hospital care delivery to improve observation services for children. OUs have been established with laudable goalsto reduce inpatient admissions, increase patient safety, improve efficiency, and control costs. The current evidence is not adequate to determine if this model of healthcare delivery achieves these goals for children. Through synthesis of existing data, we have identified a need for standard reporting for OU outcomes and propose consistent measures for future observation care research. Only through prospective evaluation of comparable outcomes can we appraise the performance of pediatric OUs across institutions.
The first observation units were implemented more than 40 years ago with the goal of reducing the number and duration of inpatient stays. Since then, observation units (OUs) have evolved as a safe alternative to hospitalization14 for the delivery of finite periods of care, typically less than 24 hours.58 Observation services allow for time to determine the need for hospitalization in cases that are unclear after their initial evaluation and treatment.9 Observation status is an administrative classification related to reimbursement that can be applied to patients whose diagnosis, treatment, stabilization, and discharge can reasonably be expected within 24 hours.10, 11 The site of care for observation is dependent in part upon existing facility structures; some institutions utilize virtual OUs within the emergency department (ED) or hospital ward, while others have dedicated, geographically distinct OUs, which may function as an extension of either the ED or inpatient settings.9
OUs have been instrumental in providing care to adult patients with chest pain, asthma, and acute infections.1218 Recently, there has been an increase in the number of publications from pediatric OUs in the United States and abroad. Observation may be a preferred model of care for select pediatric patients, as hospitalized children often experience brief stays.1921 Previous reviews on this model of care have combined adult and pediatric literature and have included research from countries with healthcare structures that differ considerably from the United States.2224 To date, no systematic review has summarized the pediatric OU literature with a focus on the US healthcare system.
As payers and hospitals seek cost‐effective alternatives to traditional inpatient care, geographically distinct OUs may become integral to the future of healthcare delivery for children. This systematic review provides a descriptive overview of the structure and function of pediatric OUs in the United States. We also scrutinize the outcome measures presented in the included publications and propose future directions for research to improve both observation unit care, as well as the care delivered to patients under observation status within general inpatient or ED settings.
Methods
Literature Search
With the assistance of a health services librarian, a search of the following electronic databases from January 1, 1950 through February 5, 2009 was conducted: 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. Key words used for the Boolean search are included in Appendix A. In addition, we conducted a manual search of reference lists from reviews, guidelines, and articles meeting inclusion criteria.
We included English language peer‐reviewed publications that reported on pediatric OU care in the United States. Studies were included if they reported outcomes including lengths of stay, admission from observation rates, return visit rates, costs or charges. Descriptive publications of pediatric OU structure and function were also included. Studies were excluded if they were conducted outside the United States, evaluated psychiatric or intensive care, reported on observation status in an ED without an OU or observation status on a traditional inpatient ward. Two reviewers (M.M. and C.K.) identified articles for inclusion. Any disagreements between the reviewers were resolved by discussion and consensus agreement. Interrater reliability was assessed using the kappa statistic.
Quality Assessment
The quality of each study was rated using the Oxford Centre for Evidence‐based Medicine levels of evidence.25 With this system, levels of evidence range from 1a (homogeneous systematic review of randomized, controlled trials) to 5 (expert opinion without explicit critical appraisal).
Data Synthesis
Data on study design, OU characteristics, patient populations, and outcomes were extracted using a standardized form. Heterogeneity of study design, interventions, and outcomes precluded the ability to conduct meta‐analyses.
Results
A systematic search of the electronic databases identified 222 unique citations (Figure 1). A total of 107 abstracts were evaluated. We identified 48 articles for full‐text review, of which 18 met inclusion criteria. Hand search of references yielded 24 additional articles, of which 3 met inclusion criteria. Interrater agreement for selected articles was high at 98% (kappa = 0.85).
Observation Unit Characteristics
The majority of research on OUs has been conducted at large academic pediatric centers. One publication was from a community hospital.26 These studies present data on more than 22,000 children cared for in OUs of 11 hospitals over a 32‐year time span. Most studies were level 2 evidence: 2b, retrospective cohort studies and low‐quality randomized, controlled trials; or 2c, outcomes research. Three were descriptive and not assigned a formal evidence level.2729
Table 1 highlights general features of U.S. pediatric OUs. Five institutions renovated or expanded clinical space in order to open the OU.27, 2932 Units ranged in size from 3 to 23 beds. The OU was located in or near the ED in all but 2 hospitals, which had ward‐based units. The ED was the primary entry point into the OU with only 2 open model units accepting patients from other settings.5, 32 The annual number of observation cases ranged from 1000 to 3000 in children's hospitals. Approximately 500 ward‐based observation cases per year were cared for in the single community hospital studied. Three reports included time trends showing increased OU utilization over study years.5, 30, 31
| Publication (Year); Condition | Study Design; Level of Evidence; Time Frame; Sample Size | Hospital; Observation Setting; Year Opened | Site | Beds | Entry Point | Staffing; Physicians; Nurses |
|---|---|---|---|---|---|---|
| ||||||
| Gururaj et al.43 (1972); all conditions | Retrospective cohort; 2c; 1 year; 437 cases under observation | King's County Downstate Brooklyn; short‐stay unit | ED | 3 | Not reported | Pediatric residents; general pediatricians |
| Ellerstein and Sullivan,32 (1980); all conditions | Retrospective cohort; 2c; 6 years; 5858 cases of unscheduled care plus 1403 elective surgery cases | Children's Hospital Buffalo; observation unit; 1972 | ED | 8 | ED, clinic, procedure/OR | Primary care pediatricians; other specialists; pediatric residents |
| O'Brien et al.37 (1980); asthma | Retrospective cohort; 2c; 1 month; 434 cases of asthma, 328 discharged directly from ED, 106 treated in holding unit | Children's National DC; holding unit | ED | 6 | ED | 1‐2 pediatric residents; 1‐2 nurses |
| Willert et al.35 (1985); asthma | Randomized*; 2b; 578 cases of asthma; 166 cases 1.5 hours postaminophylline, 103 randomized, 52 to holding unit | Children's Memorial Chicago; holding room | ED | 5 | ED | General pediatricians; pediatric residents; PEM nurses |
| Listernick et al.38 (1986); dehydration | Randomized; 2b; 29 cases of dehydration; 22 to holding unit | Children's Memorial Chicago | ||||
| Balik et al.31 (1988); all conditions | Descriptive; none given | Minneapolis Children's; short‐stay unit observation area; 1985 | Day surgery area adjacent to ED | Not reported | Not reported | General pediatricians; pediatric nurses (shared with ED) |
| Marks et al.7 (1997); all conditions | Retrospective cohort; 2c; 5 months; 968 cases in short‐stay unit | Children's Hospital Boston; short‐stay unit; 1994 | Ward | 4‐18 | ED | Primary care pediatricians; PEM physicians; pediatric residents; pediatric nurses; 1:6 nurse:patient ratio |
| Marks et al.7 (1997); asthma | Pre‐post; 2b; 400 cases of asthma; 102 pre/298 post short‐stay unit | Children's Hospital Boston | ||||
| Wiley et al.6 (1998); all conditions | Retrospective cohort; 2c; 1 year; 805 cases of unscheduled observation; plus 595 scheduled cases | Connecticut Children's; outpatient extended treatment site | ED | 10 | Not reported | PEM physicians; other specialists; 1:5 nurse:patient ratio |
| Scribano et al.65 (2001); all conditions | Retrospective cohort; 2b; 2 years; 1798 cases under observation | Connecticut Children's | ||||
| Leduc et al.30 (2002); all conditions | Retrospective cohort; 2c; 6 months; 686 cases under observation (4.8% of ED visits) | Children's Hospital Denver; OU | ED | 6 | Not reported | Not reported |
| Bajaj and Roback,30 (2003); intussusception | Retrospective cohort; 2b; 4.5 years; 78 cases of intussusception (51 under observation) | Children's Hospital Denver | ||||
| Wathen et al.36 (2004); dehydration | Convenience sample; 2c; 10 months; 182 cases of dehydration (48 under observation) | Children's Hospital Denver | ||||
| Crocetti et al.26 (2004); all conditions | Retrospective cohort; 2b; 2 years; 956 cases under observation | John Hopkin's Bayview; observation status beds; 1997 | Ward | Not reported | 99% ED 1% other location | General pediatricians covering ED and ward |
| Silvestri et al.29 (2005); all conditions | Descriptive; none given | Children's Hospital of Philadelphia; OU; 1999 | ED | 12 | ED | PEM physicians; PEM fellows; urgent care pediatricians; ED nurse practitioner; inpatient nurses |
| Alpern et al.34 (2008); all conditions | Prospective cohort; 1b; 30 months; 4453 cases under observation | Children's Hospital of Philadelphia | ||||
| Thomas27 (2000); all conditions | Descriptive; none given | Primary Children's Medical Center; RTU; 1999 | ED | 22‐26 | ED, clinic, procedure/OR | PEM physicians; general pediatricians; other specialists; no residents |
| Zebrack et al.25 (2005); all conditions | Retrospective cohort; 2b; 2 years; 4189 cases of unscheduled observation plus 2288 scheduled cases | Primary Children's Medical Center | PEM nurses; 1:4 nurse:patient ratio | |||
| Miescier et al.40 (2005); asthma | Retrospective cohort; 2b; 2 years; 3029 asthma visits; 384 admitted, 301 observed, 161cases met inclusion | Primary Children's Medical Center | ||||
| Holsti et al.41 (2005); head injury | Retrospective cohort; 2b; 2 years; 827 CHI visits, 273 admitted, 285 observed, 284 cases met inclusion | Primary Children's Medical Center | ||||
| Greenberg et al.42 (2006); croup | Retrospective pre‐post; 2b; 1 year each; 694 croup cases pre‐RTU, 66 admitted; 789 croup cases post‐RTU, 33 admitted; 76 observed | Primary Children's Medical Center | ||||
| Mallory et al.33 (2006); dehydration | Retrospective cohort; 2b; 1 year; 430 dehydration cases under observation | Primary Children's Medical Center | ||||
Staffing and Workflow
Staffing models varied and have undergone transitions over time. Prior to 1997, general pediatricians primarily provided physician services. In more recent years, OUs have utilized pediatric emergency medicine (PEM) providers. Three of the 11 units allowed for direct patient care by subspecialists.5, 6, 32 One OU was staffed by nurse practitioners.29 OU nursing backgrounds included pediatrics, emergency medicine, or PEM.
Five institutions assembled multidisciplinary teams to define the unit's role and establish policies and procedures.7, 27, 2931 Workflow in the OU focused on optimizing efficiency through standardized orders, condition‐specific treatment protocols, and bedside charting.7, 26, 33 Several units emphasized the importance of ongoing evaluations by attending physicians who could immediately respond to patient needs. Rounds occurred as often as every 4 hours.5, 7 Two centers utilized combined physician‐nursing rounds to enhance provider communication.7, 34 No publications reported on patient transitions between sites of care or at shift changes.
Criteria for Observation
All 11 hospitals have developed protocols to guide OU admissions (Table 2). Nine publications from 4 OUs commented on treatments delivered prior to observation.33, 3542 The most commonly cited criteria for admission was approval by the unit's supervising physician. Utilization review was not mentioned as an element in the OU admission decision. Common OU exclusions were the need for intensive care or monitoring while awaiting an inpatient bed; however, these were not universal. Eight centers placed bounds around the duration of OU stays, with minimum stays of 2 hours and maximum stays of 8 to 24 hours.
| Hospital | Entry Criteria | Age Range | Time | Exclusion Criteria |
|---|---|---|---|---|
| ||||
| King's County, Downstate Brooklyn | Otherwise required inpatient admission | 0‐13 years | Maximum 24 hours | Not reported |
| Acute problem of uncertain severity | ||||
| Acute problem not readily diagnosed | ||||
| Short course periodic treatment | ||||
| Diagnostic procedures impractical as outpatient | ||||
| Children's Hospital, Buffalo | Admission from any source | 0‐21 years | Maximum 24 hours | Intensive care needs |
| Short stay elective surgery | Routine diagnostic tests | |||
| Estimated length of stay <24 hours | Holding prior to admission | |||
| Children's National, Washington, DC | Inadequate response to 3 subcutaneous epinephrine injections | 8 months to 19 years | Not reported | Not reported |
| Children's Memorial, Chicago | Asthma: | |||
| Available parentAsthma score 5Inadequate response to ED treatment | >1 year | Maximum 24 hours | Past history of BPD, CF, CHD, other debilitating disease | |
| Dehydration: | ||||
| Cases receiving oral hydration | 3‐24 months | 12 hours for oral | Intensive care need | |
| Parent preference if given IV hydration | 8 to 12 hours for IV | Hypernatremia | ||
| Minneapolis Children's | Conditions listed in Table 3 | Not reported | Maximum 10 hours | Not reported |
| Children's Hospital, Boston | Straightforward diagnoses as determined by ED staff | Not reported | Not reported | Other complex medical issues |
| Bed availability | ||||
| Connecticut Children's | PEM attending discretionLimited severity of illnessUsually confined to a single organ systemClearly identified plan of care | Not reported | After 3‐4 hours in ED Low likelihood of requiring extended care >23 hours | Asthma: no supplemental O2 need, nebulized treatments >Q2 hourCroup: no supplemental O2 need, <2 racemic epinephrine treatmentsDehydration: inability to tolerate orals, bicarbonate >10, 40 mL/kg IVFSeizure: partial or generalized, postictal, unable to tolerate oralsPoisoning: mild or no symptoms, poison control recommendation |
| Children's Hospital, Denver | Intussusception: following reduction | 0‐18 years | After 3‐4 hours in ED | Not reported |
| Dehydration: based on clinical status | ||||
| Johns Hopkins, Bayview | Consultation with on‐duty pediatrician | 0‐18 years | Minimum of 2 hours | Patients requiring subspecialty or intensive care services |
| High likelihood of discharge at 24 hours | ||||
| Children's Hospital of Philadelphia | Sole discretion of the ED attending | Not reported | Minimum 4 hours | No direct admissions |
| Single focused acute condition | Maximum 23 hours | Diagnostic dilemmas | ||
| Clinical conditions appropriate for observation | Underlying complex medical problems | |||
| Primary Children's Medical Center | Observation unit attending discretion | 0‐21 years | Minimum 3 hours | Admission holds |
| Scheduled procedures as space available | Maximum 24 hours | Intensive care needs | ||
| ED admit after consult with OU doctor | Complicated, multisystem disease | |||
| Clear patient care goals | Need for multiple specialty consults | |||
| Limited severity of illness | Psychiatric patients | |||
| Diagnostic evaluation | ||||
Ages of Children Under Observation
Seven of 11 hospitals reported the age range of patients accepted in their OU (Table 2). All but 1 unit accepted children from infants to young adults, 18 to 21 years of age.43 In the 6 units that reported the age distribution of their OU population, roughly 20% were <1 year, more than 50% were <5 years, and fewer than 30% fell into an adolescent age range.5, 6, 26, 32, 34, 43
Conditions Under Observation
Many conditions under observation were common across time and location (Table 3). The list of conditions cared for in OUs has expanded in recent years. Medical conditions predominated over surgical. While the majority of observation cases required acute care, nearly one‐half of the units accepted children with scheduled care needs (eg, routine postoperative care, procedures requiring sedation, infusions, and extended evaluations such as electroencephalograms or pH probes). These scheduled cases, cared for within the OU structure, provided more steady demand for OU services.
| King's County, Downstate Brooklyn | Children's Hospital, Buffalo | Minneapolis Children's | Children's Hospital, Boston | Connecticut Children's | Children's Hospital, Denver | Johns Hopkins, Bayview | Children's Hospital of Philadelphia | Primary Children's Medical Center, Salt Lake City | |
|---|---|---|---|---|---|---|---|---|---|
| |||||||||
| Respiratory | |||||||||
| Asthma | |||||||||
| Pneumonia | |||||||||
| Bronchiolitis | |||||||||
| Croup | |||||||||
| Allergic reaction | |||||||||
| Cardiology | |||||||||
| Gastrointestinal | |||||||||
| Vomiting | |||||||||
| Gastro/dehydration | |||||||||
| Abdominal pain | |||||||||
| Constipation | |||||||||
| Diabetes | |||||||||
| Neurologic | |||||||||
| Seizure | |||||||||
| Head injury | |||||||||
| Infection | |||||||||
| Sepsis evaluation | |||||||||
| UTI/pyelonephritis | |||||||||
| Cellulitis | |||||||||
| Fever | |||||||||
| Pharyngitis | |||||||||
| Otitis media | |||||||||
| Adenitis | |||||||||
| Ingestion/poisoning | |||||||||
| Hematologic | |||||||||
| Sickle cell disease | |||||||||
| Transfusion/emnfusion | |||||||||
| Psychological/social | |||||||||
| Dental | |||||||||
| Surgical conditions | |||||||||
| Foreign body | |||||||||
| Trauma | |||||||||
| Burn | |||||||||
| Orthopaedic injury | |||||||||
| Postoperative complication | |||||||||
| Scheduled care | |||||||||
| Diagnostic workup | |||||||||
| Procedures/sedation | |||||||||
| Elective surgery | |||||||||
Reimbursement
One publication highlighted the special billing rules that must be considered for observation care.27 In 3 studies, payers recognized cost‐savings associated with the OU's ability to provide outpatient management for cases that would traditionally require inpatient care.31, 35, 38
Observation Unit Outcomes
Outcomes reported for pediatric OU stays fall into 4 major categories: length of stay (LOS), admission rates, return visit rates, and costs. Despite these seemingly straightforward groupings, there was significant heterogeneity in reporting these outcomes.
Length of Stay
The start time for OU length of stay (LOS) is not clearly defined in the articles included in this review. While the start of an observation period is assumed to begin at the time the order for observation is placed, it is possible that the LOS reported in these publications began at the time of ED arrival or the time the patient was physically transferred to the OU. The average LOS for individual OUs ranged from 10 to 15 hours.5, 6, 26, 30, 35, 38, 40, 41, 43 One ward‐based and 1 ED‐based unit reported LOS extending beyond 24 hours,7, 30 with averages of 35 and 9 hours, respectively. Two units limited the duration of care to <10 hours.31, 38
For studies that included a comparison group, OU stays were consistently shorter than a traditional inpatient stay by 6 to 110 hours.7, 36, 38, 39, 42 No significant differences in clinical parameters between groups were reported. There was appreciable variation in the average LOS across institutions for similar conditions, 12 to 35 hours for asthma,5, 7, 34, 35 and 9 to 18 hours for dehydration.5, 34, 36, 38
Admission Rates
Rates of hospital admission after observation from the 9 OUs reporting this outcome are presented in Table 4. Three publications from a single institution counted hospital admission in the 48 to 72 hours following discharge from the OU as though the patient were admitted to the hospital directly from the index OU stay.33, 40, 41 Conditions with the lowest admission rates, <10%, included croup, neurologic conditions, ingestions, trauma, and orthopedic injuries. The highest admission rates, >50%, were for respiratory conditions including asthma, pneumonia, and bronchiolitis.
| King's County, Downstate Brooklyn (%) | Children's Hospital, Buffalo (%) | Connecticut Children's (%) | Johns Hopkins, Bayview (%) | Children's Hospital of Philadelphia (%) | Primary Children's Medical Center, Salt Lake City (%) | |
|---|---|---|---|---|---|---|
| ||||||
| Unscheduled care | 42 | 17 | 11 | 25 | 25 | 15 |
| Respiratory | 32 | |||||
| Asthma | 57 | 16 | 26 | 22 | 22‐25* | |
| Pneumonia | 50 | 23 | 30‐48 | |||
| Bronchiolitis | 46 | 32 | 43 | |||
| Croup | 9 | 17 | 9 | 4‐6 | ||
| Allergic reaction | 3 | |||||
| Cardiology | 22 | |||||
| Gastrointestinal | 43 | 19 | ||||
| Vomiting | 5 | 22 | ||||
| Gastro/dehydration | 23 | 15/21 | 16* | |||
| Abdominal pain | 9 | 17 | 27 | |||
| Constipation | 9 | |||||
| Diabetes | 17 | |||||
| Neurologic | 10 | |||||
| Seizure | 19 | 8 | 17 | 18 | ||
| Head injury | 7 | 5* | ||||
| Infection | 19 | 34 | ||||
| Sepsis evaluation | 25 | 22 | ||||
| UTI/pyelonephritis | 25 | 16 | ||||
| Cellulitis | 15 | |||||
| Fever | 16 | 26 | ||||
| Pharyngitis | 13 | |||||
| Otitis media | 21 | |||||
| Ingestion/poisoning | 9 | 4 | 4 | 9 | 10 | 5 |
| Hematologic | 23 | |||||
| Transfusion/emnfusion | 2 | |||||
| Psychological/social | 21 | 80 | 17 | |||
| Dental | 14 | |||||
| Surgical conditions | ||||||
| Foreign body | ||||||
| Trauma | 13 | 2 | 53 | 5 | ||
| Burn | 13 | |||||
| Orthopedic injury | 22 | 3 | ||||
| Postoperative complication | 26 | 16 | ||||
| Scheduled care | ||||||
| Diagnostic workup | 0‐5 | |||||
| Procedures/sedation | 0.1‐9.0 | |||||
| Elective surgery | 13 | 0‐5 | ||||
Return Visit Rates
Unscheduled return visit rates were reported in 9 publications from 6 institutions and ranged from 0.01% to 5%.7, 26, 33, 3537, 3941 Follow‐up timeframes ranged from 48 hours to 1 month. Return visits were inconsistently defined. In most studies, rates were measured in terms of ED visits.26, 33, 3537, 39, 41 One ward‐based unit counted only hospital readmissions toward return visit rates.7 Three publications, from ED‐based units, counted hospital readmissions in the 2 to 5 days following observation toward admission rates and not as return visits.33, 40, 41 In most studies, data on return visits were collected from patient logs or patient tracking systems. Three studies contacted patients by phone and counted return visits to the clinic.3537 No studies reported on adherence to scheduled visits following observation.
Costs
Seven studies reported financial benefits of OU care when compared with traditional hospital care.7, 30, 31, 35, 37, 38, 42 Two centers admitted patients to inpatient care if their observation period reached a set time limit, after which cost savings were no longer realized.31, 35 Cost savings associated with the OU treatment of asthma and dehydration were attributed to lower charges for an OU bed.35, 38 Decreased charges for the OU treatment of croup were related to shorter LOS.42
Discussion
In the 40 years since the first studies of pediatric OUs, several US health systems have extended observation services to children. This model of care may be expanding, as suggested by an increase in the number of publications in the past 10 years. However, the number of centers within the US reporting on their OU experience remains small. Our systematic review identified a recurrent theme related to OUsthe opportunity to improve operational processes of care compared with the traditional inpatient alternative. We have identified the need to standardize OU outcomes and propose measures for future OU research.
Observation Unit Operations
The OU care model expands outpatient management of acute conditions to include children who are neither ready for discharge nor clear candidates for inpatient admission. OUs have demonstrated the ability to care for patients across the pediatric age spectrum. Over the decades spanning these publications, advances in medical therapy such as antiemetics for gastroenteritis and early administration of systemic steroids for asthma may have resulted in lower admission rates or shorter time to recovery.44, 45 Despite these advances, there are marked consistencies in the conditions cared for within OUs over time. The data summarized here may help guide institutions as they consider specific pediatric conditions amenable to observation care.
The hospitals included in this review either added physical space or revised services within existing structures to establish their OU. Hospitals facing physical constraints may look to underutilized areas, such as recovery rooms, to provide observation care, as observation does not require the use of licensed inpatient beds. Several units have responded to daily fluctuations in unscheduled observation cases by also serving patients who require outpatient procedures, brief therapeutic interventions, and diagnostic testing. By caring for patients with these scheduled care needs during the day, there is a more steady flow of patients into the OU. While hospitals traditionally have used postanesthesia care units and treatment rooms for scheduled cases, OUs appear to benefit from the consistent resource allocation associated with a constant demand for services.
To date, the vast majority of pediatric OUs in the published literature have emerged as an extension of ED services. Now, with the expansion of pediatric hospitalist services and movement toward 24/7 inpatient physician coverage, there may be increased development of ward‐based OUs and the designation of inpatient observation status. While ward‐based OUs managed by pediatric hospitalists may be well established, we were not able to identify published reports on this structure of care. A national survey of health systems should be undertaken to gather information regarding the current state of pediatric observation services.
When creating policies and procedures for OUs, input should be sought from stakeholders including hospitalists, PEM providers, primary care providers, subspecialists, mid‐level providers, nurses, and ancillary staff. As patients requiring observation level of care do not neatly fit an outpatient or inpatient designation, they present an opportunity for hospitalist and PEM physician groups to collaborate.4648 Calling on the clinical experiences of inpatient and ED providers could offer unique perspectives leading to the development of innovative observation care models.
This review focused on institutions with dedicated observation services, which in all but 1 study26 consisted of a defined geographic unit. It is possible that the practices implemented in an OU could have hospital‐wide impact. For example, 1 study reported reduction in LOS for all asthma cases after opening a ward‐based unit.7 Further, pediatric hospitalist services have been associated with shorter LOS49 and increased use of observation status beds compared with traditional ward services.50 As pediatric hospitalists expand their scope of practice to include both observation and inpatient care, clinical practice may be enhanced across these care areas. It follows that the impact of observation protocols on care in the ward setting should be independently evaluated.
The costs associated with the establishment and daily operations of an OU were not addressed in the reviewed publications. Assertions that observation provides a cost‐effective alternative to inpatient care4, 7, 23, 42 should be balanced by the possibility that OUs extend care for patients who could otherwise be discharged directly home. Studies have not evaluated the cost of OU care compared with ED care alone. Research is also needed to assess variations in testing and treatment intensity in OUs compared with the ED and inpatient alternatives. Reimbursement for observation is dependent in part upon institutional contracts with payers. A full discussion of reimbursement issues around observation services is beyond the scope of this review.
Observation Unit Outcomes
Length of Stay
Although most studies reported LOS, direct comparisons across institutions are difficult given the lack of a consistently referenced start to the observation period. Without this, LOS could begin at the time of ED arrival, time of first treatment, or time of admission to the OU. Identifying and reporting the elements contributing to LOS for observation care is necessary. The time of OU admission is important for billing considerations; the time of first treatment is important to understanding the patient's response to medical interventions; the time of ED arrival is important to evaluating ED efficiency. Each of these LOS measures should be reported in future studies.
Direct comparisons of LOS are further complicated by variability in the maximum permissible duration of an OU stay, ranging from 8 to 24 hours in the included studies. Despite these limits, some OU care will extend beyond set limits due to structural bottlenecks. For example, once the inpatient setting reaches capacity, observation LOS for patients who require admission will be prolonged. The best evaluation of LOS would come from prospective study design utilizing either randomization or quality improvement methods.
Defining Success and Failure in Observation Care
In the reviewed literature, observation failures have been defined in terms of admission after observation and unscheduled return visit rates. Admission rates are heavily dependent on appropriate selection of cases for observation. Although some observation cases are expected to require inpatient admission, OUs should question the validity of their unit's acceptance guidelines if the rate of admission is >30%.51 High rates could be the result of inadequate treatment or the selection of children too sick to improve within 24 hours. Low rates could indicate overutilization of observation for children who could be discharged directly home. Full reporting on the number of children presenting with a given condition and the different disposition pathways for each is needed to evaluate the success of OUs. Condition‐specific benchmarks for admission after observation rates could guide hospitals in their continuous improvement processes.
Unscheduled return visits may reflect premature discharge from care, diagnostic errors, or development of a new illness. OU care may influence patient adherence to scheduled follow‐up care but this has not been evaluated to date. In future research, both scheduled and unscheduled return visits following ED visits, observation stays, and brief inpatient admissions for similar disease states should be reported for comparison. Standard methodology for identifying return visits should include medical record review, claims analyses, and direct patient contact.
As hospitals function at or near capacity,52, 53 it becomes important to delineate the appropriate length of time to monitor for response to treatments in a given setting. Limited capacity was a frequently cited reason for opening a pediatric OU; however, the impact of OUs on capacity has not yet been evaluated. Operations research methods could be used to model OU services' potential to expand hospital capacity. This research could be guided by evaluation of administrative data from across institutions to identify current best practices for pediatric OU and observation status care.
OU benchmarking in the United States has begun with a small number of adult units participating in the ED OU Benchmark Alliance (EDOBA).54 In Table 5, we propose dashboard measures for pediatric OU continuous quality improvement. The proposed measures emphasize the role of observation along the continuum of care for acute conditions, from the ED through the OU with or without an inpatient stay to clinic follow‐up. Depending on the structure of observation services, individual institutions may select to monitor different dashboard measures from the proposed list. Patient safety and quality of care measures for the conditions commonly receiving pediatric OU care should also be developed.
| ED |
OU |
Inpatient |
Clinic | |
|---|---|---|---|---|
| ||||
| Length of stay* | ED arrival to OU admission | OU admit to disposition | Inpatient admit to discharge | |
| ED arrival to discharge home from OU | ||||
| ED arrival to discharge from inpatient following OU care | ||||
| OU admission to discharge home from inpatient care | ||||
| Admission* | % ED census admitted inpatient | % OU census admitted | ||
| % ED census that is observed | ||||
| Unscheduled return visits* | To ED | Requiring OU admission | Requiring inpatient admission | |
| Scheduled follow‐up* | To ED | To primary care or subspecialist office | ||
| Capacity | ED crowding scales | Unable to accept transfers | ||
| ED left before evaluation rates | Inpatient occupancy | |||
| Ambulance diversion | ||||
| Satisfaction | Patient/Parent | |||
| ED providers | OU providers | Inpatient providers | Follow‐up providers | |
| Cost | ED care | OU care | Inpatient care | |
| Total encounter | ||||
Limitations
The most important limitations to this review are the heterogeneity in interventions and reporting of outcomes, which precluded our ability to combine data or conduct meta‐analyses. We attempted to organize the outcomes data into clear and consistent groupings. However, we could not compare the performance of 1 center with another due to differences in OU structure, function, and design.
In order to focus this systematic review, we chose to include only peer reviewed publications that describe pediatric OUs within the United States. This excludes expert guidelines, which may be of value to institutions developing observation services.
Our search found only a small number of centers that utilize OUs and have published their experience. Thus, our review is likely subject to publication bias. Along this line, we identified 9 additional publications where children were cared for alongside adults within a general OU.5563 This suggests an unmeasured group of children under observation in general EDs, where more than 90% of US children receive acute care.64 These articles were excluded because we were unable to distinguish pediatric specific outcomes from the larger study population.
Finally, retrospective study design is subject to information bias. Without a comparable control group, it is difficult to understand the effects of OUs. Patients directly admitted or discharged from the ED and patients who require admission after observation all differ from patients discharged from observation in ways that should be controlled for with a randomized study design.
Conclusions
OUs have emerged to provide treatment at the intersection of outpatient and inpatient care during a time of dramatic change in both emergency and hospital medicine. As hospitalists expand their scope of practice to include observation care, opportunities will arise to collaborate with ED physicians and share their growing expertise in quality and efficiency of hospital care delivery to improve observation services for children. OUs have been established with laudable goalsto reduce inpatient admissions, increase patient safety, improve efficiency, and control costs. The current evidence is not adequate to determine if this model of healthcare delivery achieves these goals for children. Through synthesis of existing data, we have identified a need for standard reporting for OU outcomes and propose consistent measures for future observation care research. Only through prospective evaluation of comparable outcomes can we appraise the performance of pediatric OUs across institutions.
- .Observation medicine.Acad Emerg Med.1994;1(2):152–154.
- ,.Principles of observation medicine.Emerg Med Clin North Am.2001;19(1):1–17.
- ,,, et al.Emergency department observation beds improve patient care: Society for Academic Emergency Medicine debate.Ann Emerg Med.1992;21(8):967–975.
- .Pediatric observation medicine.Emerg Med Clin North Am.2001;19(1):239–254.
- ,,.The pediatric hybrid observation unit: an analysis of 6477 consecutive patient encounters.Pediatrics.2005;115(5):e535–e542.
- ,,, et al.Observation units: the role of an outpatient extended treatment site in pediatric care.Pediatr Emerg Care.1998;14(6):444–447.
- ,,, et al.Impact of a short stay unit on asthma patients admitted to a tertiary pediatric hospital.Qual Manag Health Care.1997;6(1):14–22.
- ,,, et al.Management of observation units. American College of Emergency Physicians.Ann Emerg Med.1995;25(6):823–830.
- ,,, et al. The observation unit: an operational overview for the hospitalist. Society of Hospital Medicine White Paper 2009; Available at: http://www.hospitalmedicine.org/Content/NavigationMenu/Publications/WhitePapers/White_Papers.htm. Accessed July2009.
- Acute Criteria Pediatric InterQual Level of Care.San Francisco, CA:McKesson Corporation;2006.
- Observation Status Related to U.S. Hospital Records.Healthcare Cost and Utilization Project. HCUP Methods Series Report #2002‐3. Rockville, MD: Agency for Healthcare Research and Quality;2002.
- ,,, et al.Emergency department observation unit versus hospital inpatient care for a chronic asthmatic population: a randomized trial of health status outcome and cost.Med Care.1998;36(4):599–609.
- ,,, et al.Costs of an emergency department‐based accelerated diagnostic protocol vs hospitalization in patients with chest pain: a randomized controlled trial.JAMA.1997;278(20):1670–1676.
- .Management of patients with infectious diseases in an emergency department observation unit.Emerg Med Clin North Am.2001;19(1):187–207.
- ,,, et al.A comparison between emergency diagnostic and treatment unit and inpatient care in the management of acute asthma.Arch Intern Med.1997;157(18):2055–2062.
- .Chest pain observation units.Emerg Med J.2001;18(2):148.
- ,,, et al.Randomised controlled trial and economic evaluation of a chest pain observation unit compared with routine care.BMJ.2004;328(7434):254.
- ,,, et al.A cooperative care model: cardiologists and hospitalists reduce length of stay in a chest pain observation. In:5th Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke, Washington, DC, May 15‐17, 2003.Philadelphia, PA:Lippincott Williams 2003. p.P186.
- ,.Observation unit management of pediatric emergencies.Emerg Med Clin North Am.1991;9(3):669–676.
- .A short stay or 23‐hour ward in a general and academic children's hospital: are they effective?Pediatr Emerg Care.2000;16(4):223–229.
- ,,, et al.Trends in high turnover stays among children hospitalized in the United States, 1993 through 2003.Pediatrics.2009;123:996–1002.
- .Hospital based alternatives to acute paediatric admission: a systematic review.Arch Dis Child.2005;90(2):138–142.
- ,,.Short‐stay units and observation medicine: a systematic review.Med J Aust.2003;178(11):559–563.
- ,,.Use of emergency observation and assessment wards: a systematic literature review.Emerg Med J.2003;20(2):138–142.
- Oxford Centre for Evidence‐Based Medicine. Levels of evidence and grades of recommendation (May 2001). Available at: http://www.cebm.net/levels_of_evidence.asp. Accessed July2009.
- ,,, et al.Pediatric observation status beds on an inpatient unit: an integrated care model.Pediatr Emerg Care.2004;20(1):17–21.
- .Pediatric update. Our new rapid treatment unit: an innovative adaptation of the “less than 24‐hour stay” holding unit.J Emerg Nurs.2000;26(5):507.
- ,,.Use of an observation unit by a pediatric emergency department for common pediatric illnesses.Pediatr Emerg Care.2001;17(5):321–323.
- ,,, et al.Observation medicine: the expanded role of the nurse practitioner in a pediatric emergency department extended care unit.Pediatr Emerg Care.2005;21(3):199–202.
- ,,.An observation unit in a pediatric emergency department: one children's hospital's experience.J Emerg Nurs.2002;28(5):407–413.
- ,,.When the patient requires observation not hospitalization.J Nurs Admin.1988;18(10):20–23.
- ,.Observation unit in Children's Hospital—Adjunct to delivery and teaching of ambulatory pediatric care.N Y State J Med.1980;80(11):1684–1686.
- ,,, et al.Use of pediatric observation unit for treatment of children with dehydration caused by gastroenteritis.Pediatr Emerg Care.2006;22(1):1–6.
- ,,, et al.Utilization and unexpected hospitalization rates of a pediatric emergency department 23‐hour observation unit.Pediatr Emerg Care.2008;24(9):589–594.
- ,,, et al.Short‐term holding room treatment of asthmatic‐children.J Pediatr.1985;106(5):707–711.
- ,,.Usefulness of the serum electrolyte panel in the management of pediatric dehydration treated with intravenously administered fluids.Pediatrics.2004;114(5):1227–1234.
- ,,.Treatment of acute asthmatic attacks in a holding unit of a pediatric emergency room.Ann Allergy.1980;45(3):159–162.
- ,,.Outpatient oral rehydration in the United States.Am J Dis Child.1986;140(3):211–215.
- ,.Postreduction management of intussusception in a children's hospital emergency department.Pediatrics.2003;112(6 Pt 1):1302–1307.
- ,,, et al.Children with asthma admitted to a pediatric observation unit.Pediatr Emerg Care.2005;21(10):645–649.
- ,,, et al.Pediatric closed head injuries treated in an observation unit.Pediatr Emerg Care.2005;21(10):639–644.
- ,,.A reduction in hospitalization, length of stay, and hospital charges for croup with the institution of a pediatric observation unit.Am J Emerg Med.2006;24(7):818–821.
- ,,.Short stay in an outpatient department. An alternative to hospitalization.Am J Dis Child.1972;123(2):128–132.
- ,,.The role of oral ondansetron in children with vomiting as a result of acute gastritis/gastroenteritis who have failed oral rehydration therapy: a randomized controlled trial.Ann Emerg Med.2008;52(1):22–29.e6.
- ,,, et al.Oral ondansetron for gastroenteritis in a pediatric emergency department.N Engl J Med.2006;354(16):1698–1705.
- ,,, et al.Integrated hospital emergency care improves efficiency.Emerg Med J.2008;25(2):78–82.
- ,,, et al.Redefining the community pediatric hospitalist: the combined pediatric ED/inpatient unit.Pediatr Emerg Care.2007;23(1):33–37.
- ,,, et al.Program description: a hospitalist‐run, medical short‐stay unit in a teaching hospital.CMAJ.2000;163(11):1477–1480.
- ,.Evaluation of a pediatric hospitalist service: impact on length of stay and hospital charges.Pediatrics.2000;105(3 Pt 1):478–484.
- ,,, et al.Restructuring an academic pediatric inpatient service using concepts developed by hospitalists.Clin Pediatr (Phila).2001;40(12):653–660; discussion 661‐662.
- ,,, et al.American College of Emergency Physicians (ACEP).Practice Management Committee, American College of Emergency Physicians. Management of Observation Units. Irving, TX: American College of Emergency Physicians; July1994.
- Overcrowding crisis in our nation's emergency departments:is our safety net unraveling?Pediatrics.2004;114(3):878–888.
- ,.Emergency department overcrowding in the United States: an emerging threat to patient safety and public health.Emerg Med J.2003;20(5):402–405.
- ,,, et al.Characteristics of high volume teaching hospital observation units: data from the Emergency Department Observation Unit Benchmark Alliance (EDOBA).Acad Emerg Med.2009;16(s1):Abstract 628.
- ,,.Use of the emergency department observation unit in the treatment of acute asthma.Ann Emerg Med.1982;11(2):77–83.
- ,,, et al.Management of acute pyelonephritis in an emergency department observation unit.[see Comment].Ann Emerg Med.1991;20(3):253–257.
- ,,, et al.Patterns of use of an emergency department‐based observation unit.Am J Ther.2002;9(6):499–502.
- ,,, et al.Emergency department observation of poisoned patients: how long is necessary?[see Comment].Acad Emerg Med.1999;6(9):887–894.
- ,,, et al.False‐negative and false‐positive errors in abdominal pain evaluation: failure to diagnose acute appendicitis and unnecessary surgery.Acad Emerg Med.2000;7(11):1244–1255.
- .Resource use by younger versus older patients.Fam Pract Res J.1993;13(3):283–290.
- ,,, et al.Trauma 24‐hour observation critical path.J Trauma.1998;45(1):147–150.
- ,,, et al.The role of an emergency department observation unit in the management of trauma patients.J Emerg Med.1985;2(5):325–333.
- ,.Observation unit impact on ED admission for asthma.Am J Emerg Med.1994;12(1):11–14.
- ,.Emergency care for children in pediatric and general emergency departments.Pediatr Emerg Care.2007;23(2):94–102.
- .Observation medicine.Acad Emerg Med.1994;1(2):152–154.
- ,.Principles of observation medicine.Emerg Med Clin North Am.2001;19(1):1–17.
- ,,, et al.Emergency department observation beds improve patient care: Society for Academic Emergency Medicine debate.Ann Emerg Med.1992;21(8):967–975.
- .Pediatric observation medicine.Emerg Med Clin North Am.2001;19(1):239–254.
- ,,.The pediatric hybrid observation unit: an analysis of 6477 consecutive patient encounters.Pediatrics.2005;115(5):e535–e542.
- ,,, et al.Observation units: the role of an outpatient extended treatment site in pediatric care.Pediatr Emerg Care.1998;14(6):444–447.
- ,,, et al.Impact of a short stay unit on asthma patients admitted to a tertiary pediatric hospital.Qual Manag Health Care.1997;6(1):14–22.
- ,,, et al.Management of observation units. American College of Emergency Physicians.Ann Emerg Med.1995;25(6):823–830.
- ,,, et al. The observation unit: an operational overview for the hospitalist. Society of Hospital Medicine White Paper 2009; Available at: http://www.hospitalmedicine.org/Content/NavigationMenu/Publications/WhitePapers/White_Papers.htm. Accessed July2009.
- Acute Criteria Pediatric InterQual Level of Care.San Francisco, CA:McKesson Corporation;2006.
- Observation Status Related to U.S. Hospital Records.Healthcare Cost and Utilization Project. HCUP Methods Series Report #2002‐3. Rockville, MD: Agency for Healthcare Research and Quality;2002.
- ,,, et al.Emergency department observation unit versus hospital inpatient care for a chronic asthmatic population: a randomized trial of health status outcome and cost.Med Care.1998;36(4):599–609.
- ,,, et al.Costs of an emergency department‐based accelerated diagnostic protocol vs hospitalization in patients with chest pain: a randomized controlled trial.JAMA.1997;278(20):1670–1676.
- .Management of patients with infectious diseases in an emergency department observation unit.Emerg Med Clin North Am.2001;19(1):187–207.
- ,,, et al.A comparison between emergency diagnostic and treatment unit and inpatient care in the management of acute asthma.Arch Intern Med.1997;157(18):2055–2062.
- .Chest pain observation units.Emerg Med J.2001;18(2):148.
- ,,, et al.Randomised controlled trial and economic evaluation of a chest pain observation unit compared with routine care.BMJ.2004;328(7434):254.
- ,,, et al.A cooperative care model: cardiologists and hospitalists reduce length of stay in a chest pain observation. In:5th Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke, Washington, DC, May 15‐17, 2003.Philadelphia, PA:Lippincott Williams 2003. p.P186.
- ,.Observation unit management of pediatric emergencies.Emerg Med Clin North Am.1991;9(3):669–676.
- .A short stay or 23‐hour ward in a general and academic children's hospital: are they effective?Pediatr Emerg Care.2000;16(4):223–229.
- ,,, et al.Trends in high turnover stays among children hospitalized in the United States, 1993 through 2003.Pediatrics.2009;123:996–1002.
- .Hospital based alternatives to acute paediatric admission: a systematic review.Arch Dis Child.2005;90(2):138–142.
- ,,.Short‐stay units and observation medicine: a systematic review.Med J Aust.2003;178(11):559–563.
- ,,.Use of emergency observation and assessment wards: a systematic literature review.Emerg Med J.2003;20(2):138–142.
- Oxford Centre for Evidence‐Based Medicine. Levels of evidence and grades of recommendation (May 2001). Available at: http://www.cebm.net/levels_of_evidence.asp. Accessed July2009.
- ,,, et al.Pediatric observation status beds on an inpatient unit: an integrated care model.Pediatr Emerg Care.2004;20(1):17–21.
- .Pediatric update. Our new rapid treatment unit: an innovative adaptation of the “less than 24‐hour stay” holding unit.J Emerg Nurs.2000;26(5):507.
- ,,.Use of an observation unit by a pediatric emergency department for common pediatric illnesses.Pediatr Emerg Care.2001;17(5):321–323.
- ,,, et al.Observation medicine: the expanded role of the nurse practitioner in a pediatric emergency department extended care unit.Pediatr Emerg Care.2005;21(3):199–202.
- ,,.An observation unit in a pediatric emergency department: one children's hospital's experience.J Emerg Nurs.2002;28(5):407–413.
- ,,.When the patient requires observation not hospitalization.J Nurs Admin.1988;18(10):20–23.
- ,.Observation unit in Children's Hospital—Adjunct to delivery and teaching of ambulatory pediatric care.N Y State J Med.1980;80(11):1684–1686.
- ,,, et al.Use of pediatric observation unit for treatment of children with dehydration caused by gastroenteritis.Pediatr Emerg Care.2006;22(1):1–6.
- ,,, et al.Utilization and unexpected hospitalization rates of a pediatric emergency department 23‐hour observation unit.Pediatr Emerg Care.2008;24(9):589–594.
- ,,, et al.Short‐term holding room treatment of asthmatic‐children.J Pediatr.1985;106(5):707–711.
- ,,.Usefulness of the serum electrolyte panel in the management of pediatric dehydration treated with intravenously administered fluids.Pediatrics.2004;114(5):1227–1234.
- ,,.Treatment of acute asthmatic attacks in a holding unit of a pediatric emergency room.Ann Allergy.1980;45(3):159–162.
- ,,.Outpatient oral rehydration in the United States.Am J Dis Child.1986;140(3):211–215.
- ,.Postreduction management of intussusception in a children's hospital emergency department.Pediatrics.2003;112(6 Pt 1):1302–1307.
- ,,, et al.Children with asthma admitted to a pediatric observation unit.Pediatr Emerg Care.2005;21(10):645–649.
- ,,, et al.Pediatric closed head injuries treated in an observation unit.Pediatr Emerg Care.2005;21(10):639–644.
- ,,.A reduction in hospitalization, length of stay, and hospital charges for croup with the institution of a pediatric observation unit.Am J Emerg Med.2006;24(7):818–821.
- ,,.Short stay in an outpatient department. An alternative to hospitalization.Am J Dis Child.1972;123(2):128–132.
- ,,.The role of oral ondansetron in children with vomiting as a result of acute gastritis/gastroenteritis who have failed oral rehydration therapy: a randomized controlled trial.Ann Emerg Med.2008;52(1):22–29.e6.
- ,,, et al.Oral ondansetron for gastroenteritis in a pediatric emergency department.N Engl J Med.2006;354(16):1698–1705.
- ,,, et al.Integrated hospital emergency care improves efficiency.Emerg Med J.2008;25(2):78–82.
- ,,, et al.Redefining the community pediatric hospitalist: the combined pediatric ED/inpatient unit.Pediatr Emerg Care.2007;23(1):33–37.
- ,,, et al.Program description: a hospitalist‐run, medical short‐stay unit in a teaching hospital.CMAJ.2000;163(11):1477–1480.
- ,.Evaluation of a pediatric hospitalist service: impact on length of stay and hospital charges.Pediatrics.2000;105(3 Pt 1):478–484.
- ,,, et al.Restructuring an academic pediatric inpatient service using concepts developed by hospitalists.Clin Pediatr (Phila).2001;40(12):653–660; discussion 661‐662.
- ,,, et al.American College of Emergency Physicians (ACEP).Practice Management Committee, American College of Emergency Physicians. Management of Observation Units. Irving, TX: American College of Emergency Physicians; July1994.
- Overcrowding crisis in our nation's emergency departments:is our safety net unraveling?Pediatrics.2004;114(3):878–888.
- ,.Emergency department overcrowding in the United States: an emerging threat to patient safety and public health.Emerg Med J.2003;20(5):402–405.
- ,,, et al.Characteristics of high volume teaching hospital observation units: data from the Emergency Department Observation Unit Benchmark Alliance (EDOBA).Acad Emerg Med.2009;16(s1):Abstract 628.
- ,,.Use of the emergency department observation unit in the treatment of acute asthma.Ann Emerg Med.1982;11(2):77–83.
- ,,, et al.Management of acute pyelonephritis in an emergency department observation unit.[see Comment].Ann Emerg Med.1991;20(3):253–257.
- ,,, et al.Patterns of use of an emergency department‐based observation unit.Am J Ther.2002;9(6):499–502.
- ,,, et al.Emergency department observation of poisoned patients: how long is necessary?[see Comment].Acad Emerg Med.1999;6(9):887–894.
- ,,, et al.False‐negative and false‐positive errors in abdominal pain evaluation: failure to diagnose acute appendicitis and unnecessary surgery.Acad Emerg Med.2000;7(11):1244–1255.
- .Resource use by younger versus older patients.Fam Pract Res J.1993;13(3):283–290.
- ,,, et al.Trauma 24‐hour observation critical path.J Trauma.1998;45(1):147–150.
- ,,, et al.The role of an emergency department observation unit in the management of trauma patients.J Emerg Med.1985;2(5):325–333.
- ,.Observation unit impact on ED admission for asthma.Am J Emerg Med.1994;12(1):11–14.
- ,.Emergency care for children in pediatric and general emergency departments.Pediatr Emerg Care.2007;23(2):94–102.
Hospitalists and ACC in Pandemic Flu
Major natural disasters, such as Hurricane Rita and Hurricane Katrina in 2005, have reinforced the reality that health care workers may be asked to treat patients outside the traditional hospital setting.1 The emergence of H5N1 avian influenza in Southeast Asia has also raised concerns about a potential worldwide pandemic influenza.2 Since 2003, the number of avian influenza cases in humans has totaled 387, with 245 deaths.3 While H5N1 influenza has thus far been largely confined to avian populations, the virulence of this strain has raised concern regarding the possible emergence of enhanced human transmission.4 While impossible to accurately forecast the devastation of the next pandemic on the health system, anything similar to the pandemics of the past century will require a large coordinated response by the health system. The most severe pandemic in the past century occurred in 1918 to 1919. The estimated deaths attributed to this worldwide ranges from 20 to 100 million persons,57 with >500,000 of these deaths in the United States.6, 7 In comparison, the annual rate of deaths related to influenza in the United States ranges from 30,000 to 50,000.2, 5 It has been estimated that the next pandemic influenza could cause 75 to 100 million people to become ill, and lead to as many as 1.9 million deaths in the United States.8 In response, the Department of Health and Human Services (HHS) has stressed the importance of advanced planning,9 and the most recent Homeland Security Presidential Directive (HSPD‐21) directs health care organizations and the federal government to develop preparedness plans to provide surge capacity care in times of a catastrophic health event.10 A previous report by one of the authors emphasized the need for hospitalists to play a major role in institutional planning for a pandemic influenza.11
The Alternate Care Center
The concept of offsite care in an influenza pandemic has previously been described, and we will refer to these as Alternate Care Centers (ACCs). Although the literature describes different models of care at an ACC (Table 1),12 we believe an ACC should be activated as an extension of the supporting hospital, once the hospital becomes over capacity despite measures to grow its inpatient service volume.
| Overflow hospital providing full range of care |
| Patient isolation and alternative to home care for infectious patients |
| Expanded ambulatory care |
| Care for recovering, noninfectious patients |
| Limited supportive care for noncritical patients |
| Primary triage and rapid patient screening |
| Quarantine |
Our health system is a large academic medical center, and we have been working with our state to develop a plan to establish and operate an ACC for the next pandemic influenza. Our plans call for an ACC to be activated as an overflow hospital once our hospitals are beyond 120% capacity. We have gone through several functional and tabletop exercises to help identify critical issues that are likely to arise during a real pandemic. Subsequent to these exercises, we have convened an ACC Planning Work Group, reviewed the available literature on surge hospitals, and have focused our recent efforts on several key areas.13 First, it will be important to clearly outline the general services that will be available at this offsite location (Table 2), and this information should be disseminated to the local medical community and the general public. An informed public, with a clear understanding that the ACC is an extension of the hospital with hospitalists in charge of medical care, is more likely to accept getting healthcare in this setting.
|
| IVF administration |
| Parenteral medication administration (eg, antibiotics, steroids, narcotic analgesics, antiemetics) |
| Oxygen support |
| Palliative care services |
Second, hospitals and the ACCas an extension to the main hospitalwill be asked to provide care to patients referred from several external facilities. Thus, the relationship between the ACC and the main hospital is critical. In a situation where local and even national health care assets will be overwhelmed, having a traditional hospital take full ownership of the ACC and facilitate the transport of patients in and out of the center will be vital to the maintenance of operations. Figure 1 illustrates an example of how patients may be transitioned from 1 site of care to another.
Third, the logistics of establishing an ACC should include details regarding: (1) securing a location that is able to accommodate the needs of the ACC; (2) predetermining the scope of care that can be provided; (3) procuring the necessary equipment and supplies; (4) planning for an adequate number of workforce and staff members; and (5) ensuring a reliable communication plan within the local health system and with state and federal public health officials.14 Staffing shortages and communication barriers are worthy of further emphasis. Given conservative estimates that up to 35% of staff may become ill, refuse to work, or remain home to care for ill family members,15 it is essential that hospitals and regional emergency planners develop a staffing model for the ACC, well in advance of a pandemic. These may include scenarios in which the recommended provider‐to‐patient ratio can not be met. Among the essential lessons learned from the severe acute respiratory syndrome (SARS) outbreak in Toronto (Ontario, Canada) was the importance of developing redundant and reliable communication plans among the healthcare providers.16, 17
Last, healthcare workers' concerns about occupational health and safety must be addressed, and strict measures to protect providers in the ACC need to be implemented.16 This includes providing all exposed staff with adequate personal protective equipment (eg, N‐95 masks), ensuring that all staff are vaccinated against the influenza virus, and implementing strict infection control (eg, hand washing) practices.
For more information, we refer the reader to references that contain further details on our ACC exercises13 and documents that outline concepts of operations in an ACC, developed by the Joint Commission and a multiagency working group.1, 14
The Hospitalist Physician and the ACC
During an influenza pandemic, physicians from all specialties will be vital to the success of the health systems' response. General internists,18 family practitioners, and pediatricians will be overextended in the ambulatory setting to provide intravenous (IV) fluids, antibiotics, and vaccines. Emergency physicians will be called upon to provide care for a burgeoning number of patient arrivals to the Emergency Department (ED), whose acuity is higher than in nonpandemic times. These physicians' clinical expertise at their sites of practice may be severely tested. Hospitalists, given their inpatient focus will be ideally suited to provide medical care to patients admitted to the ACC.
Previous physician leadership at surge hospitals has come from multiple specialties. Case studies describing the heroic physician leadership after Hurricane Katrina and Hurricane Rita represented pediatricians, family physicians, emergency department physicians, and internists.1 In an influenza pandemic, patients in the ACC will require medical care that would, under nonsurge situations, warrant inpatient care. Hospitalists are well poised to lead the response in the ACC for pandemic flu. Hospitalists have expanded their presence into many clinical and administrative responsibilities in their local health systems,19 and the specialty of hospital medicine has evolved to incorporate many of the skills and expertise that would be required of physician leaders who manage an ACC during an influenza pandemic.
While the actual morbidity and mortality associated with the next pandemic are uncertain, it is likely that the number of patients who seek out medical care will exceed current capacity. With constrained space and resources, patients will require appropriate and safe transition to and from the hospital and the ACC. Hospitalists have become leaders in developing and promoting quality transition of care out of acute care settings.20, 21 Their expertise in optimizing this vulnerable time period in patients' healthcare experience should help hospitalists make efficient and appropriate transition care decisions even during busy times and in an alternate care location. Many hospitalists have also developed local and national expertise in quality improvement (QI) and patient safety (PS) initiatives in acute care settings.22 Hospitalists can lead the efforts to apply QI and PS practices in the ACC. These interventions should focus on the potential to be effective in improving patient care, but also consider issues such as ease of implementation, cost, and potential for harm.23
An influenza pandemic will require all levels of the healthcare system to work together to develop a coordinated approach to patient care. Previously, Kisuule et al.24 described how hospitalists can expand their role to include public health. The hospitalists' leadership in the ACC fits well with their descriptions, and hospitalists should work with local, state, and national public health officials in pandemic flu planning. Their scope of practice and clinical expertise will call on them to play key roles in recognition of the development of a pandemic; help lead the response efforts; provide education to staff, patients, and family members; develop clinical care guidelines and pathways for patients; utilize best practices in the use of antimicrobial therapy; and provide appropriate palliative care. Depending on the severity of the influenza pandemic, mortality could be considerable. Many hospitalists have expertise in palliative care at their hospitals,2527 and this skill set will be invaluable in providing compassionate end‐of‐life care to patients in the ACC.
In a pandemic, the most vulnerable patient populations will likely be disproportionately affected, including the elderly, children, and the immune‐compromised. Hospitalists who care regularly for these diverse groups of patients through the spectrum of illness and recovery will be able to address the variety of clinical and nonclinical issues that arise. If the ACC will provide care for children, hospitalists with training in pediatrics, medicine‐pediatrics, or family medicine should be available.
Additional Considerations
While many unanswered questions remain about how to best utilize the ACC, hospitalists are ideally suited to help lead planning efforts for an ACC for pandemic flu. Other issues that may require additional considerations include: (1) whether to strictly care for patients with influenza symptoms and influenza‐related illnesses or to provide care for all patients at the ACC; (2) what to do when patients refuse transfer to and from the ACC; (3) determining the optimal staffing model for patient care providers and to provide care for a wide range of age groups; (4) how the ACC will be funded; (5) how and where to store stockpiles; (6) developing redundant and coordinated communication plans; and (7) planning for reliable access to information and technology from the ACC.
Conclusions
We have introduced the concept of the ACC for the hospitalist community, and emphasized the benefits of engaging hospitalists to lead the ACC initiative at their own health organizations during pandemic flu. As hospitalists currently serve in many of these roles and possess the skills to provide care and lead these initiatives, we encourage hospitalists to contact their hospital administrators to volunteer to assist with preparation efforts.
- Joint Commission on Accreditation of Healthcare Organizations. Surge Hospitals: Providing Safe Care in Emergencies;2006. Available at: http://www.jointcommission.org/NR/rdonlyres/802E9DA4‐AE80‐4584‐A205‐48989C5BD684/0/surge_hospital.pdf. Accessed May 2009.
- .Pandemic influenza: are we ready?Disaster Manag Response.2005;3(3):61–67.
- Cumulative Number of Confirmed Human Cases of Avian Influenza A/(H5N1) Reported to WHO.2008. Available at: http://www.who.int/csr/disease/avian_influenza/country/cases_table_2008_09_10/en/index.html. Accessed May 2009.
- ,,, et al.Human infection with highly pathogenic H5N1 influenza virus.Lancet.2008;371(9622):1464–1475.
- .Preparing for the next pandemic.N Engl J Med.2005;352(18):1839–1842.
- ,,.Influenza pandemic preparedness action plan for the United States: 2002 update.Clin Infect Dis.2002;35(5):590–596.
- ,,, et al.Nonpharmaceutical interventions implemented by US cities during the 1918‐1919 influenza pandemic.JAMA.2007;298(6):644–654.
- The Health Care Response to Pandemic Influenza: Position Paper.Philadelphia, PA:American College of Physicians;2006.
- U.S. Department of Health and Human Services (HHS). HHS Pandemic Influenza Plan. November2005. Available at: http://www.hhs.gov/pandemicflu/plan. Accessed May 2009.
- Homeland Security Presidential Directive/HSPD‐21.2007. Available at: http://www.whitehouse.gov/news/releases/2007/10/20071018‐10.html. Accessed May 2009.
- ,.Pandemic influenza and the hospitalist: apocalypse when?J Hosp Med.2006;1(2):118–123.
- ,,,,.The prospect of using alternative medical care facilities in an influenza pandemic.Biosecur Bioterror.2006;4(4):384–390.
- ,,, et al.Pandemic influenza and acute care centers (ACCs): taking care of sick patients in a non‐hospital setting.Biosecur Bioterror.2008;6(4):335–348.
- ,,.Acute Care Center. Modular Emergency Medical System: Concept of Operations for the Acute Care Center (ACC).Mass Casualty Care Strategy for A Biological Terrorism Incident. May2003. Available at: http://dms.dartmouth.edu/nnemmrs/resources/surge_capacity_guidance/documents/acute_care_center__concept_ of_operations. pdf. Accessed May 2009.
- Illinois Department of Public Health. Influenza.2007. Available at: http://www.idph.state.il.us/flu/pandemicfs.htm. Accessed May 2009.
- ,,.Learning from SARS in Hong Kong and Toronto.JAMA.2004;291(20):2483–2487.
- .Planning for epidemics—the lessons of SARS.N Engl J Med.2004;350(23):2332–2334.
- .The role of internists during epidemics, outbreaks, and bioterrorist attacks.J Gen Intern Med.2007;22(1):131–136.
- ,.The expanding role of hospitalists in the United States.Swiss Med Wkly.2006;136(37‐38):591–596.
- ,,,.Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists.J Hosp Med.2007;2(5):314–323.
- ,.Executing high‐quality care transitions: a call to do it right.J Hosp Med.2007;2(5):287–290.
- .Reflections: the hospitalist movement a decade later.J Hosp Med.2006;1(4):248–252.
- ,.Implementing patient safety interventions in your hospital: what to try and what to avoid.Med Clin North Am.2008;92(2):275–293, vii‐viii.
- ,,,.Expanding the roles of hospitalist physicians to include public health.J Hosp Med.2007;2(,2):93–101.
- ,,,,,.Evaluating the California hospital initiative in palliative services.Arch Intern Med.2006;166(2):227–230.
- .Palliative care and hospitalists: a partnership for hope.J Hosp Med.2006;1(1):5–6.
- .Palliative care in hospitals.J Hosp Med.2006;1(1):21–28.
Major natural disasters, such as Hurricane Rita and Hurricane Katrina in 2005, have reinforced the reality that health care workers may be asked to treat patients outside the traditional hospital setting.1 The emergence of H5N1 avian influenza in Southeast Asia has also raised concerns about a potential worldwide pandemic influenza.2 Since 2003, the number of avian influenza cases in humans has totaled 387, with 245 deaths.3 While H5N1 influenza has thus far been largely confined to avian populations, the virulence of this strain has raised concern regarding the possible emergence of enhanced human transmission.4 While impossible to accurately forecast the devastation of the next pandemic on the health system, anything similar to the pandemics of the past century will require a large coordinated response by the health system. The most severe pandemic in the past century occurred in 1918 to 1919. The estimated deaths attributed to this worldwide ranges from 20 to 100 million persons,57 with >500,000 of these deaths in the United States.6, 7 In comparison, the annual rate of deaths related to influenza in the United States ranges from 30,000 to 50,000.2, 5 It has been estimated that the next pandemic influenza could cause 75 to 100 million people to become ill, and lead to as many as 1.9 million deaths in the United States.8 In response, the Department of Health and Human Services (HHS) has stressed the importance of advanced planning,9 and the most recent Homeland Security Presidential Directive (HSPD‐21) directs health care organizations and the federal government to develop preparedness plans to provide surge capacity care in times of a catastrophic health event.10 A previous report by one of the authors emphasized the need for hospitalists to play a major role in institutional planning for a pandemic influenza.11
The Alternate Care Center
The concept of offsite care in an influenza pandemic has previously been described, and we will refer to these as Alternate Care Centers (ACCs). Although the literature describes different models of care at an ACC (Table 1),12 we believe an ACC should be activated as an extension of the supporting hospital, once the hospital becomes over capacity despite measures to grow its inpatient service volume.
| Overflow hospital providing full range of care |
| Patient isolation and alternative to home care for infectious patients |
| Expanded ambulatory care |
| Care for recovering, noninfectious patients |
| Limited supportive care for noncritical patients |
| Primary triage and rapid patient screening |
| Quarantine |
Our health system is a large academic medical center, and we have been working with our state to develop a plan to establish and operate an ACC for the next pandemic influenza. Our plans call for an ACC to be activated as an overflow hospital once our hospitals are beyond 120% capacity. We have gone through several functional and tabletop exercises to help identify critical issues that are likely to arise during a real pandemic. Subsequent to these exercises, we have convened an ACC Planning Work Group, reviewed the available literature on surge hospitals, and have focused our recent efforts on several key areas.13 First, it will be important to clearly outline the general services that will be available at this offsite location (Table 2), and this information should be disseminated to the local medical community and the general public. An informed public, with a clear understanding that the ACC is an extension of the hospital with hospitalists in charge of medical care, is more likely to accept getting healthcare in this setting.
|
| IVF administration |
| Parenteral medication administration (eg, antibiotics, steroids, narcotic analgesics, antiemetics) |
| Oxygen support |
| Palliative care services |
Second, hospitals and the ACCas an extension to the main hospitalwill be asked to provide care to patients referred from several external facilities. Thus, the relationship between the ACC and the main hospital is critical. In a situation where local and even national health care assets will be overwhelmed, having a traditional hospital take full ownership of the ACC and facilitate the transport of patients in and out of the center will be vital to the maintenance of operations. Figure 1 illustrates an example of how patients may be transitioned from 1 site of care to another.
Third, the logistics of establishing an ACC should include details regarding: (1) securing a location that is able to accommodate the needs of the ACC; (2) predetermining the scope of care that can be provided; (3) procuring the necessary equipment and supplies; (4) planning for an adequate number of workforce and staff members; and (5) ensuring a reliable communication plan within the local health system and with state and federal public health officials.14 Staffing shortages and communication barriers are worthy of further emphasis. Given conservative estimates that up to 35% of staff may become ill, refuse to work, or remain home to care for ill family members,15 it is essential that hospitals and regional emergency planners develop a staffing model for the ACC, well in advance of a pandemic. These may include scenarios in which the recommended provider‐to‐patient ratio can not be met. Among the essential lessons learned from the severe acute respiratory syndrome (SARS) outbreak in Toronto (Ontario, Canada) was the importance of developing redundant and reliable communication plans among the healthcare providers.16, 17
Last, healthcare workers' concerns about occupational health and safety must be addressed, and strict measures to protect providers in the ACC need to be implemented.16 This includes providing all exposed staff with adequate personal protective equipment (eg, N‐95 masks), ensuring that all staff are vaccinated against the influenza virus, and implementing strict infection control (eg, hand washing) practices.
For more information, we refer the reader to references that contain further details on our ACC exercises13 and documents that outline concepts of operations in an ACC, developed by the Joint Commission and a multiagency working group.1, 14
The Hospitalist Physician and the ACC
During an influenza pandemic, physicians from all specialties will be vital to the success of the health systems' response. General internists,18 family practitioners, and pediatricians will be overextended in the ambulatory setting to provide intravenous (IV) fluids, antibiotics, and vaccines. Emergency physicians will be called upon to provide care for a burgeoning number of patient arrivals to the Emergency Department (ED), whose acuity is higher than in nonpandemic times. These physicians' clinical expertise at their sites of practice may be severely tested. Hospitalists, given their inpatient focus will be ideally suited to provide medical care to patients admitted to the ACC.
Previous physician leadership at surge hospitals has come from multiple specialties. Case studies describing the heroic physician leadership after Hurricane Katrina and Hurricane Rita represented pediatricians, family physicians, emergency department physicians, and internists.1 In an influenza pandemic, patients in the ACC will require medical care that would, under nonsurge situations, warrant inpatient care. Hospitalists are well poised to lead the response in the ACC for pandemic flu. Hospitalists have expanded their presence into many clinical and administrative responsibilities in their local health systems,19 and the specialty of hospital medicine has evolved to incorporate many of the skills and expertise that would be required of physician leaders who manage an ACC during an influenza pandemic.
While the actual morbidity and mortality associated with the next pandemic are uncertain, it is likely that the number of patients who seek out medical care will exceed current capacity. With constrained space and resources, patients will require appropriate and safe transition to and from the hospital and the ACC. Hospitalists have become leaders in developing and promoting quality transition of care out of acute care settings.20, 21 Their expertise in optimizing this vulnerable time period in patients' healthcare experience should help hospitalists make efficient and appropriate transition care decisions even during busy times and in an alternate care location. Many hospitalists have also developed local and national expertise in quality improvement (QI) and patient safety (PS) initiatives in acute care settings.22 Hospitalists can lead the efforts to apply QI and PS practices in the ACC. These interventions should focus on the potential to be effective in improving patient care, but also consider issues such as ease of implementation, cost, and potential for harm.23
An influenza pandemic will require all levels of the healthcare system to work together to develop a coordinated approach to patient care. Previously, Kisuule et al.24 described how hospitalists can expand their role to include public health. The hospitalists' leadership in the ACC fits well with their descriptions, and hospitalists should work with local, state, and national public health officials in pandemic flu planning. Their scope of practice and clinical expertise will call on them to play key roles in recognition of the development of a pandemic; help lead the response efforts; provide education to staff, patients, and family members; develop clinical care guidelines and pathways for patients; utilize best practices in the use of antimicrobial therapy; and provide appropriate palliative care. Depending on the severity of the influenza pandemic, mortality could be considerable. Many hospitalists have expertise in palliative care at their hospitals,2527 and this skill set will be invaluable in providing compassionate end‐of‐life care to patients in the ACC.
In a pandemic, the most vulnerable patient populations will likely be disproportionately affected, including the elderly, children, and the immune‐compromised. Hospitalists who care regularly for these diverse groups of patients through the spectrum of illness and recovery will be able to address the variety of clinical and nonclinical issues that arise. If the ACC will provide care for children, hospitalists with training in pediatrics, medicine‐pediatrics, or family medicine should be available.
Additional Considerations
While many unanswered questions remain about how to best utilize the ACC, hospitalists are ideally suited to help lead planning efforts for an ACC for pandemic flu. Other issues that may require additional considerations include: (1) whether to strictly care for patients with influenza symptoms and influenza‐related illnesses or to provide care for all patients at the ACC; (2) what to do when patients refuse transfer to and from the ACC; (3) determining the optimal staffing model for patient care providers and to provide care for a wide range of age groups; (4) how the ACC will be funded; (5) how and where to store stockpiles; (6) developing redundant and coordinated communication plans; and (7) planning for reliable access to information and technology from the ACC.
Conclusions
We have introduced the concept of the ACC for the hospitalist community, and emphasized the benefits of engaging hospitalists to lead the ACC initiative at their own health organizations during pandemic flu. As hospitalists currently serve in many of these roles and possess the skills to provide care and lead these initiatives, we encourage hospitalists to contact their hospital administrators to volunteer to assist with preparation efforts.
Major natural disasters, such as Hurricane Rita and Hurricane Katrina in 2005, have reinforced the reality that health care workers may be asked to treat patients outside the traditional hospital setting.1 The emergence of H5N1 avian influenza in Southeast Asia has also raised concerns about a potential worldwide pandemic influenza.2 Since 2003, the number of avian influenza cases in humans has totaled 387, with 245 deaths.3 While H5N1 influenza has thus far been largely confined to avian populations, the virulence of this strain has raised concern regarding the possible emergence of enhanced human transmission.4 While impossible to accurately forecast the devastation of the next pandemic on the health system, anything similar to the pandemics of the past century will require a large coordinated response by the health system. The most severe pandemic in the past century occurred in 1918 to 1919. The estimated deaths attributed to this worldwide ranges from 20 to 100 million persons,57 with >500,000 of these deaths in the United States.6, 7 In comparison, the annual rate of deaths related to influenza in the United States ranges from 30,000 to 50,000.2, 5 It has been estimated that the next pandemic influenza could cause 75 to 100 million people to become ill, and lead to as many as 1.9 million deaths in the United States.8 In response, the Department of Health and Human Services (HHS) has stressed the importance of advanced planning,9 and the most recent Homeland Security Presidential Directive (HSPD‐21) directs health care organizations and the federal government to develop preparedness plans to provide surge capacity care in times of a catastrophic health event.10 A previous report by one of the authors emphasized the need for hospitalists to play a major role in institutional planning for a pandemic influenza.11
The Alternate Care Center
The concept of offsite care in an influenza pandemic has previously been described, and we will refer to these as Alternate Care Centers (ACCs). Although the literature describes different models of care at an ACC (Table 1),12 we believe an ACC should be activated as an extension of the supporting hospital, once the hospital becomes over capacity despite measures to grow its inpatient service volume.
| Overflow hospital providing full range of care |
| Patient isolation and alternative to home care for infectious patients |
| Expanded ambulatory care |
| Care for recovering, noninfectious patients |
| Limited supportive care for noncritical patients |
| Primary triage and rapid patient screening |
| Quarantine |
Our health system is a large academic medical center, and we have been working with our state to develop a plan to establish and operate an ACC for the next pandemic influenza. Our plans call for an ACC to be activated as an overflow hospital once our hospitals are beyond 120% capacity. We have gone through several functional and tabletop exercises to help identify critical issues that are likely to arise during a real pandemic. Subsequent to these exercises, we have convened an ACC Planning Work Group, reviewed the available literature on surge hospitals, and have focused our recent efforts on several key areas.13 First, it will be important to clearly outline the general services that will be available at this offsite location (Table 2), and this information should be disseminated to the local medical community and the general public. An informed public, with a clear understanding that the ACC is an extension of the hospital with hospitalists in charge of medical care, is more likely to accept getting healthcare in this setting.
|
| IVF administration |
| Parenteral medication administration (eg, antibiotics, steroids, narcotic analgesics, antiemetics) |
| Oxygen support |
| Palliative care services |
Second, hospitals and the ACCas an extension to the main hospitalwill be asked to provide care to patients referred from several external facilities. Thus, the relationship between the ACC and the main hospital is critical. In a situation where local and even national health care assets will be overwhelmed, having a traditional hospital take full ownership of the ACC and facilitate the transport of patients in and out of the center will be vital to the maintenance of operations. Figure 1 illustrates an example of how patients may be transitioned from 1 site of care to another.
Third, the logistics of establishing an ACC should include details regarding: (1) securing a location that is able to accommodate the needs of the ACC; (2) predetermining the scope of care that can be provided; (3) procuring the necessary equipment and supplies; (4) planning for an adequate number of workforce and staff members; and (5) ensuring a reliable communication plan within the local health system and with state and federal public health officials.14 Staffing shortages and communication barriers are worthy of further emphasis. Given conservative estimates that up to 35% of staff may become ill, refuse to work, or remain home to care for ill family members,15 it is essential that hospitals and regional emergency planners develop a staffing model for the ACC, well in advance of a pandemic. These may include scenarios in which the recommended provider‐to‐patient ratio can not be met. Among the essential lessons learned from the severe acute respiratory syndrome (SARS) outbreak in Toronto (Ontario, Canada) was the importance of developing redundant and reliable communication plans among the healthcare providers.16, 17
Last, healthcare workers' concerns about occupational health and safety must be addressed, and strict measures to protect providers in the ACC need to be implemented.16 This includes providing all exposed staff with adequate personal protective equipment (eg, N‐95 masks), ensuring that all staff are vaccinated against the influenza virus, and implementing strict infection control (eg, hand washing) practices.
For more information, we refer the reader to references that contain further details on our ACC exercises13 and documents that outline concepts of operations in an ACC, developed by the Joint Commission and a multiagency working group.1, 14
The Hospitalist Physician and the ACC
During an influenza pandemic, physicians from all specialties will be vital to the success of the health systems' response. General internists,18 family practitioners, and pediatricians will be overextended in the ambulatory setting to provide intravenous (IV) fluids, antibiotics, and vaccines. Emergency physicians will be called upon to provide care for a burgeoning number of patient arrivals to the Emergency Department (ED), whose acuity is higher than in nonpandemic times. These physicians' clinical expertise at their sites of practice may be severely tested. Hospitalists, given their inpatient focus will be ideally suited to provide medical care to patients admitted to the ACC.
Previous physician leadership at surge hospitals has come from multiple specialties. Case studies describing the heroic physician leadership after Hurricane Katrina and Hurricane Rita represented pediatricians, family physicians, emergency department physicians, and internists.1 In an influenza pandemic, patients in the ACC will require medical care that would, under nonsurge situations, warrant inpatient care. Hospitalists are well poised to lead the response in the ACC for pandemic flu. Hospitalists have expanded their presence into many clinical and administrative responsibilities in their local health systems,19 and the specialty of hospital medicine has evolved to incorporate many of the skills and expertise that would be required of physician leaders who manage an ACC during an influenza pandemic.
While the actual morbidity and mortality associated with the next pandemic are uncertain, it is likely that the number of patients who seek out medical care will exceed current capacity. With constrained space and resources, patients will require appropriate and safe transition to and from the hospital and the ACC. Hospitalists have become leaders in developing and promoting quality transition of care out of acute care settings.20, 21 Their expertise in optimizing this vulnerable time period in patients' healthcare experience should help hospitalists make efficient and appropriate transition care decisions even during busy times and in an alternate care location. Many hospitalists have also developed local and national expertise in quality improvement (QI) and patient safety (PS) initiatives in acute care settings.22 Hospitalists can lead the efforts to apply QI and PS practices in the ACC. These interventions should focus on the potential to be effective in improving patient care, but also consider issues such as ease of implementation, cost, and potential for harm.23
An influenza pandemic will require all levels of the healthcare system to work together to develop a coordinated approach to patient care. Previously, Kisuule et al.24 described how hospitalists can expand their role to include public health. The hospitalists' leadership in the ACC fits well with their descriptions, and hospitalists should work with local, state, and national public health officials in pandemic flu planning. Their scope of practice and clinical expertise will call on them to play key roles in recognition of the development of a pandemic; help lead the response efforts; provide education to staff, patients, and family members; develop clinical care guidelines and pathways for patients; utilize best practices in the use of antimicrobial therapy; and provide appropriate palliative care. Depending on the severity of the influenza pandemic, mortality could be considerable. Many hospitalists have expertise in palliative care at their hospitals,2527 and this skill set will be invaluable in providing compassionate end‐of‐life care to patients in the ACC.
In a pandemic, the most vulnerable patient populations will likely be disproportionately affected, including the elderly, children, and the immune‐compromised. Hospitalists who care regularly for these diverse groups of patients through the spectrum of illness and recovery will be able to address the variety of clinical and nonclinical issues that arise. If the ACC will provide care for children, hospitalists with training in pediatrics, medicine‐pediatrics, or family medicine should be available.
Additional Considerations
While many unanswered questions remain about how to best utilize the ACC, hospitalists are ideally suited to help lead planning efforts for an ACC for pandemic flu. Other issues that may require additional considerations include: (1) whether to strictly care for patients with influenza symptoms and influenza‐related illnesses or to provide care for all patients at the ACC; (2) what to do when patients refuse transfer to and from the ACC; (3) determining the optimal staffing model for patient care providers and to provide care for a wide range of age groups; (4) how the ACC will be funded; (5) how and where to store stockpiles; (6) developing redundant and coordinated communication plans; and (7) planning for reliable access to information and technology from the ACC.
Conclusions
We have introduced the concept of the ACC for the hospitalist community, and emphasized the benefits of engaging hospitalists to lead the ACC initiative at their own health organizations during pandemic flu. As hospitalists currently serve in many of these roles and possess the skills to provide care and lead these initiatives, we encourage hospitalists to contact their hospital administrators to volunteer to assist with preparation efforts.
- Joint Commission on Accreditation of Healthcare Organizations. Surge Hospitals: Providing Safe Care in Emergencies;2006. Available at: http://www.jointcommission.org/NR/rdonlyres/802E9DA4‐AE80‐4584‐A205‐48989C5BD684/0/surge_hospital.pdf. Accessed May 2009.
- .Pandemic influenza: are we ready?Disaster Manag Response.2005;3(3):61–67.
- Cumulative Number of Confirmed Human Cases of Avian Influenza A/(H5N1) Reported to WHO.2008. Available at: http://www.who.int/csr/disease/avian_influenza/country/cases_table_2008_09_10/en/index.html. Accessed May 2009.
- ,,, et al.Human infection with highly pathogenic H5N1 influenza virus.Lancet.2008;371(9622):1464–1475.
- .Preparing for the next pandemic.N Engl J Med.2005;352(18):1839–1842.
- ,,.Influenza pandemic preparedness action plan for the United States: 2002 update.Clin Infect Dis.2002;35(5):590–596.
- ,,, et al.Nonpharmaceutical interventions implemented by US cities during the 1918‐1919 influenza pandemic.JAMA.2007;298(6):644–654.
- The Health Care Response to Pandemic Influenza: Position Paper.Philadelphia, PA:American College of Physicians;2006.
- U.S. Department of Health and Human Services (HHS). HHS Pandemic Influenza Plan. November2005. Available at: http://www.hhs.gov/pandemicflu/plan. Accessed May 2009.
- Homeland Security Presidential Directive/HSPD‐21.2007. Available at: http://www.whitehouse.gov/news/releases/2007/10/20071018‐10.html. Accessed May 2009.
- ,.Pandemic influenza and the hospitalist: apocalypse when?J Hosp Med.2006;1(2):118–123.
- ,,,,.The prospect of using alternative medical care facilities in an influenza pandemic.Biosecur Bioterror.2006;4(4):384–390.
- ,,, et al.Pandemic influenza and acute care centers (ACCs): taking care of sick patients in a non‐hospital setting.Biosecur Bioterror.2008;6(4):335–348.
- ,,.Acute Care Center. Modular Emergency Medical System: Concept of Operations for the Acute Care Center (ACC).Mass Casualty Care Strategy for A Biological Terrorism Incident. May2003. Available at: http://dms.dartmouth.edu/nnemmrs/resources/surge_capacity_guidance/documents/acute_care_center__concept_ of_operations. pdf. Accessed May 2009.
- Illinois Department of Public Health. Influenza.2007. Available at: http://www.idph.state.il.us/flu/pandemicfs.htm. Accessed May 2009.
- ,,.Learning from SARS in Hong Kong and Toronto.JAMA.2004;291(20):2483–2487.
- .Planning for epidemics—the lessons of SARS.N Engl J Med.2004;350(23):2332–2334.
- .The role of internists during epidemics, outbreaks, and bioterrorist attacks.J Gen Intern Med.2007;22(1):131–136.
- ,.The expanding role of hospitalists in the United States.Swiss Med Wkly.2006;136(37‐38):591–596.
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