| Abstract|| |
Background: Reduction in admissions is an important aim of emergency department working policy to overcome the problems of a shortage of inpatient beds, rising costs and exhausted resources. A new policy was instituted in the pediatric emergency department (PED) of a hospital in Kuwait with the following components: (1) assigning senior doctor staff (2) implementation of new disease management guidelines; and (3) maximizing the use of the pediatric emergency department observation unit. Objective: to evaluate the effect of change in our policy on the admission rate. Materials and Methods: The effects of this policy on reduction of admission rates for total pediatric admissions and for some selected common pediatric conditions were prospectively studied over a period of 3 years from institution of the policy and compared with the 3-year period before the policy was instituted. Results: There was a significant reduction in admission rates after institution of the new policy. The proportion of hospital admissions to PED observation unit cases was significantly reduced as a whole from 64.9% ± 5.1% to 33.2 ± 0.6% and also for the common pediatric problems studied. Conclusion: A multidisciplinary pediatric emergency department policy, using as much available evidence as possible, was successful in significantly reducing pediatric hospital admissions.
Keywords: Change in emergency policy, pediatric admission, pediatric emergency
|How to cite this article:|
Alazmi MA, Elhassanien AF. Reduction of pediatric emergency hospital admissions by a change in pediatric emergency department policy. J Emerg Trauma Shock 2013;6:209-12
|How to cite this URL:|
Alazmi MA, Elhassanien AF. Reduction of pediatric emergency hospital admissions by a change in pediatric emergency department policy. J Emerg Trauma Shock [serial online] 2013 [cited 2020 Jan 21];6:209-12. Available from: http://www.onlinejets.org/text.asp?2013/6/3/209/115349
| Introduction|| |
Children requiring emergency care have unique and special needs. Children younger than 3 years represent the largest proportion of medically related visits. Access to optimal emergency care for children is affected by the availability of equipments, appropriately trained staff to care for children, and policies and procedures that ensures timely transfer to definitive care. , Although advances have been made that promote access to emergency care for children, marked increase in population, increasing number of visits, and improved awareness of the pediatric emergency service in hospitals, in addition to the development of regionalized and coordinated emergency care systems, increase the rate of emergency admissions to hospital. ,
On the other hand, some hospitals have difficulty due to the increasing hospital admission rates and problems with bed availability. These problems are of public, economic, and healthcare interest. 
In our hospital (Aladan Hospital), there is no triage area together with progressive increase in the number of visits to the pediatric emergency department (PED); therefore, we are usually faced with overcrowding and bed crisis. Many attempts to overcome this excess load by reducing hospital referrals and improving the quality of the primary healthcare service were not beneficial as expected.
In our PED, we have introduced new strategies aimed at improvement of the pediatric emergency service and justifying the admission to the pediatric wards. These strategies instituted had the following components: (1) assigning senior doctor staff, (2) implementation of new disease management guidelines, and (3) maximizing the use of the pediatric emergency department observation unit (PEDOU) through (a) using it as a short stay observation ward for common medical emergencies (e.g., acute exacerbation of bronchial asthma and gastroenteritis), (b) extending the length of stay, and (c) allowing its use for certain procedures such as outpatient antibiotic therapy. We observed a change in admission rate, especially for selected common medical conditions, for a 3-year period after institution of this policy. The aim of our study was to evaluate the effect of these strategies on the number of admission rates in our hospital as a general and as regards the common medical problems faced in PED.
| Materials and Methods|| |
Aladan Hospital is one of the five governmental general hospitals in Kuwait established in 1981 and now serves a population of 750,000. There were 136,915 child visits to the PED in 2011. This number does not include trauma cases or patients aged above 12 years, who are managed in the general emergency department.
In January 2009, a change in PED working policy was started, which consisted of (1) assigning senior doctor staff, (2) implementing new disease management guidelines, and (3) maximizing the use of the PEDOU. Change in our doctors staff team had started since the start of the new policy to divide the working hours in the PED into three daily shifts; each shift was covered by six doctors (one specialist, two senior registers, three registers), 15 nurses, and one social worker. As there is no triage area, patients are directed first to the vital signs room then to be first examined by the three registers doctors. If the patient`s condition needs urgent care, the patient will be directed immediately to the resuscitation room (where he/she will be seen immediately by a senior register and specialist). However, if the patient does not need urgent care, he is either managed by the registers, admitted to the PEDOU, or reassessed by the senior registers. The two senior doctors in each shift were assigned to 2 nd opinion consultation of patients referred to them from the registrars and management of patients in PEDOU. The specialist was assigned for 3 rd opinion consultation and supervision of the PEDOU. The admission/discharge decisions for medical PEDOU cases were the responsibility of the senior doctors and the specialist in the team.
International validated guidelines and protocols were chosen and approved by a panel of senior emergency doctors, and had been tested and shown to be reliable and cost-effective. Marked change had been occurring in the guides, especially for the most common pediatric emergency. The conditions studied were acute execration bronchial asthma (BA), acute gastroenteritis (AGE), urinary tract infection (UTI), pneumonia, and acute bronchiolitis. In our biweekly regular scientific meetings, these guidelines were addressed to PED doctors to follow in their practice. The selected guidelines for the medical conditions used in this study are shown in [Table 1].
The PEDOU is composed of 16 beds with cardiorespiratory monitors, infusion pumps, and other facilities. Maximizing the use of the PEDOU was undertaken by (1) extending the length of patient stay up to a maximum of 24 h, (2) allowing its use as a specialized short-stay observation unit, e.g., for AGE or mild respiratory distress due to BA with the necessary monitoring and access to investigations, (3) allowing certain procedures such as urinary catheterization for urine collection in children less than 1 year, lumber puncture for children suspected to have meningitis or encephalitis, nasogastric tube change for chronic patients, prophylactic factor 8 transfusion, and outpatient parenteral antibiotic therapy, (4) increasing access to immediate diagnostic testing such as pulmonary function test, computerized tomography scanning, ultrasonography and electrocardiogram, and (5) using it for follow-up of non-admitted patients if needed as patients with Henoch-Schonlein purpura.
The numbers of hospital visits to PED, PPEDOU cases, and hospital admissions were collected for 3 years starting from the date of application of the new policy (1 st January 2009). The numbers of PED visits and hospital admissions were obtained from the hospital recording electronic system. The PEDOU data (including numbers of patients, diagnosis, and admission/discharge numbers) were obtained from hand-filled PED registration books. The numbers for the same categories for the preceding 3 years were collected for comparison. The work was based entirely on personal efforts and was not supported by any financial or administrative motivations.
| Statistical Methods|| |
Change in the annual admission rate was calculated by comparing the means of absolute numbers of total and disease-specific medical admissions over the study and comparison periods. The P value was calculated using the unpaired samples t test. The proportions (%) of hospital pediatric admissions to the PEDOU for each disease category were calculated and comparisons were made between the two periods using means, standard deviations, and P values (Unpaired samples t test).
| Results|| |
The absolute numbers of admissions to the pediatric wards and admissions to the PEDOU during the two periods of the study are shown in [Table 2]. The proportion (%) of hospital admissions to PEDOU cases was significantly reduced for all categories, with a reduction from 64.9 ± 5.1% to 33.2 ± 0.6% (P = 0.003) for AGE, from 42 ± 6.4% to 13.7 ± 0.6% (P = 0.011) for BA, from 61.7 ± 2.5% to 44.7 ± 3.6% (P = 0.015) for UTI, from 58.8 ± 6.2% to 17.7 ± 1.4% (P = 0.003) for pneumonia, from 80.2 ± 5.5% to 33.7% ± 4.6 (P = 0.002), and for bronchiolitis, from 56.2 ± 6.4% to 27.8 ± 2.4% (P = 0.014) [Table 3].
|Table 2: Absolute numbers of admissions to PEDOU and pediatric hospital admissions during the 3-year periods before (2006-8) and after (2009-11) institution of the new policy|
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|Table 3: Statistical analysis of admission rates to PEDOU and hospital admission rates during the 3-year periods before (2006-8) and after (2009-11) institution of the new policy|
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| Discussion|| |
Emergency admissions are rising and bed crises are occurring almost daily in many hospitals. In addition, patient dissatisfaction due to increased waiting time for transfer to an inpatient bed has also become the most important cause of PED overcrowding.  Numerous methods and solutions have been proposed to solve this problem.  The main aim of our new policy was to improve the medical service together with reduction of unnecessary admissions with consequent reductions in cost and overcrowding.
Although education and training to improve management and decision-making is important for all the working staff, assigning highly qualified PED doctors guarantees responsibility and reliability in some critical circumstances. Few reports have studied the effects of assigning an admission avoidance team, , but we depend on providing highly qualified PED doctors.
Reports show that the application of disease management protocols or guidelines was effective in reducing admissions for many diseases through the PED as AGE,  BA,  pneumonia  and UTI.  In our study, applications of new chosen, unified guidelines with the beginning of the new policy were helpful to the doctors for better decision-making.
On the other hand, we modified our PEDOU to allow application of these guidelines and perform certain procedures such as parenteral antibiotic therapy. Before implementation of the policy, patients had to be admitted to hospital for parenteral antibiotic therapy as parenteral antibiotics are not given on a community basis. In a study of the effect of PEDOU on the total admission rate, Lateef et al.  reported that observation in a PEDOU resulted in a 6.4% reduction in admissions compared with direct inpatient admission. Another study by Daly et al.  showed that short-stay observation units were found to increase patient satisfaction, reduce admissions and improve cost-effectiveness.
However, in our study, modifications to the observation unit were implemented alongside the new clinical protocols, and it was not possible to distinguish the relative benefits of each. The only study of the effect of several approaches on the reduction in total medical admissions was conducted by Rossi et al.  This study showed that improving quality in emergency services by organizational, professional and economic changes resulted in an 11.2% reduction in medical hospital admissions.
In our study, the effect of the reduction in admissions on patient outcome in terms of morbidity (second hospital visits), mortality and patient satisfaction was not fully evaluated because of the large number of patients. But, using validated international protocols and guidelines is expected to produce a favorable outcome. The total effect of the reduction in admissions on cost is expected to be huge owing to the large number of avoided admissions compared with the period before implementation of the new policy. The success of our policy in significantly reducing the admission rate gives example proof that the multidisciplinary evidence-based approach is essential for PED management. We believe that any PED in a general hospital can establish or modify PEDOU and doctors can choose suitable applicable protocols to avoid unnecessary admissions.
| References|| |
|1.||Seidel JS, Gausche M. Standards for emergency departments. In: Dieckmann RA, editor. Pediatric Emergency Care Systems: Planning and Management. Baltimore, MD: Williams and Wilkins; 1992. p. 267-78. |
|2.||Moskop JC, Sklar DP, Geiderman JM, Schears RM, Bookman KJ. Emergency department crowding, part 1-concept, causes, and moral consequences. Ann Emerg Med 2009;53:605-11. |
|3.||Blatchford O, Capewell S, and Murray S, Blatchford M. Emergency medical admissions in Glasgow: General practices vary despite adjustment for age, sex, and deprivation. Br J Gen Pract 1999;49:551-4. |
|4.||Hobbs R. Rising emergency admissions. BMJ 1995;310:207-8. |
|5.||Forster AJ, Stiell I, Wells G, Lee AJ, van Walraven C. The effect of hospital occupancy on emergency department length of stay and patient disposition. Acad Emerg Med 2003;10:127-33. |
|6.||King CK, Glass R, Bresee JS, Duggan C; Centers for Disease Control and Prevention. Management acute gastroenteritis among children: Oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep 2003;52 (RR-16):1-16. |
|7.||Fonseca BK, Holgate A, Craig JC. Enteral vs. intravenous rehydration therapy for children with gastroenteritis: A meta-analysis of randomized controlled trials. Arch Pediatr Adolesc Med 2004;158:483-90. |
|8.||Global Initiative for Asthma (GINA). Available from: http://www.ginasthma.org [Last accessed on 2008]. |
|9.||Bacharier LB, Boner A, Carlsen KH, Eigenmann PA, Frischer T, Götz M, et al. Diagnosis and treatment of asthma in childhood: A PRACTALL consensus report. Allergy 2008;63:5-34. |
|10.||Chon CH, Lai FC, Shortliffe M. Pediatric urinary tract infections. Pedaitr Clin North Am 2001;6:1441-59. |
|11.||Gauthier M, Chevalier I, Sterescu A, Bergeron S, Brunet S, Taddeo D. Treatment of urinary tract infections among febrile young children with daily intravenous antibiotic therapy at a day treatment center. Pediatrics 2004;114:e469-76. |
|12.||Renaud B, Coma E, Hayon J, Gurgui M, Longo C, Blancher M, et al. Investigation of the ability of the Pneumonia Severity Index to accurately predict clinically relevant outcomes: A European study. Clin Microbiol Infect 2007;13:923-31. |
|13.||Ostapchuk M, Roberts DM, Haddy R. Community-acquired pneumonia in infants and children. Am Fam Physician 2004;70:899-908. |
|14.||Subcommittee on Diagnosis and Management of Bronchiolitis: From the American Academy of Pediatrics, Diagnosis and Management of Bronchiolitis. Pediatrics 2006;118:1774-93. |
|15.||Agency for Healthcare Research and Quality. Management of Bronchiolitis in Infants and Children. Evidence Report/Technology Assessment No. 69. Rockville, MD: Agency for Healthcare Research and Quality; 2003. AHRQ Publication No. 03-E014. |
|16.||Wardrope J, Kidner NL, Edhouse J. Bed crises are occurring almost daily in some hospitals. BMJ 1995;310:868. |
|17.||Piehl MD, Clemens CJ, Joines JD. "Narrowing the Gap": Decreasing emergency department use by children enrolled in Medicaid program by improving access to primary care. Arch Pediatr Adolesc Med 2000;154:791-5. |
|18.||Daly S, Campbell DA, Cameron PA. Short-stay units and observation medicine: A systematic review. Med J Aust 2003;178:559-63. |
|19.||Rossi P, Tosato F, Franceschinis P, Barberi M, Zuddas M, Barboni E, et al. Improving quality in emergency services to reduce hospital admission. Qual Assur Health Care 1993;5:127-9. |
|20.||Boyd R, Busuttil M, Stuart P. Pilot study of a pediatric emergency department oral rehydration protocol. Emerg Med J 2005;22:116-7. |
|21.||Connett GJ, Warde C, Wooler E, Lenney W. Audit strategies to reduce hospital admissions for acute asthma. Arch Dis Child 1993;69:202-5. |
|22.||Dean NC, Suchyta MR, Bateman KA, Aronsky DA, Hadlock CJ. Implementation of admission decision support for community-acquired pneumonia. A Pilot Study. Chest 2000;117:1368-77. |
|23.||AHRQ quality indicators. Guide to prevention quality indicators: Hospital admission for ambulatory care sensitive conditions [version 3.1]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2007. p. 59. |
|24.||Lateef F, Anantharaman V. The short-stay emergency observation ward is here to stay. Am J Emerg Med 2000;18:629-34. |
Ahmed F Elhassanien
Department of Pediatrics, Faculty of Medicine, Elmansoura University
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]