Direct Admission to Hospital: A Mixed Methods Survey of Pediatric Practices, Benefits, and Challenges

Abstract

Background Direct admissions account for 25% of pediatric unscheduled hospitalizations. Despite this, our knowledge of direct admission practices and safety is limited. This study aimed to characterize direct admission practices, benefits and challenges at a diverse sample of hospitals, and to identify diagnoses most appropriate for this admission approach. Methods We conducted a national survey at a stratified random sample of 177 US hospitals, employing both closed- and open-ended questions. Descriptive statistics were calculated to summarize numeric responses while qualitative content analysis was performed to identify emergent themes. Results Reponses were received from 108 hospitals (61%). Hospitals represented all geographic regions and employed varied emergency medicine and inpatient care models. 103 (95%) respondents reported that their hospitals accepted direct admissions and 45 (50%) expressed the view that more children should be admitted directly. Perceived benefits included: (i) improved efficiency; (ii) patient and physician satisfaction; (iii) earlier access to pediatric-specific care; (iv) continuity of care; and (v) reduced risk of nosocomial infection. Risks and challenges included: (i) difficulties determining admission appropriateness; (ii) inconsistent processes; (iii) provision of timely care; and (iv) patient safety. Populations and diagnoses reported as most appropriate and inappropriate for direct admission varied considerably across respondents. Conclusions While respondents described benefits of direct admission for both patients and healthcare systems, many also reported challenges and safety concerns. Our results may inform subsequent epidemiologic and patient-centered outcomes research to evaluate the safety and effectiveness of direct admissions.

Comparative Effectiveness of Direct Admission & Admission through Emergency Departments for Children: A Randomized Stepped Wedge Study Protocol

“…13 These quantitative data are mirrored in a national survey of pediatric medical directors reporting direct admission rates at their hospitals that range from less than 10% to greater than 50%. 16 Despite this, only one-third report having formal direct admission policies in place, while 50% report a belief that more children should be admitted directly. This significant variation across hospitals and conditions indicates clinical uncertainty regarding hospital admission best practices.…”

Direct admission to the hospital: An alternative approach to hospitalization

“…7 However, there are also risks and potential harms associated with direct admission, including potential delays in initial evaluation and management, inconsistent admission processes, and difficulties determining direct admission appropriateness, all of which could adversely impact patient safety and quality of care. 7-9 One study of adults with sepsis found that direct admission was associated with increased mortality compared to ED admission, which the authors speculated to be related to less timely care.…”

“…In our national survey of pediatric direct admission guidelines, less than one-third of hospitals reported having formal criteria to assess the appropriateness of direct admissions, and respondents’ perspectives regarding populations and diagnoses appropriate for this admission approach varied considerably. 7 These results point to the need for further research and quality improvement initiatives to inform the development of direct admission guidelines and protocols.…”

“…Direct admission offers a number of potential benefits for both patients and healthcare delivery systems including reductions in the number of sites and providers of care, improved communication and coordination between outpatient and hospital-based healthcare providers, greater patient and referring physician satisfaction, and reduced ED volumes and subsequent costs. 7 However, there are also risks and potential harms associated with direct admission, including potential delays in initial evaluation and management, inconsistent admission processes, and difficulties determining direct admission appropriateness, all of which could adversely impact patient safety and quality of care. [7][8][9] One study of adults with sepsis found that direct admission was associated with increased mortality compared to ED admission, which the authors speculated to be related to less timely care.…”

“…7 However, there are also risks and potential harms associated with direct admission, including potential delays in initial evaluation and management, inconsistent admission processes, and difficulties determining direct admission appropriateness, all of which could adversely impact patient safety and quality of care. [7][8][9] One study of adults with sepsis found that direct admission was associated with increased mortality compared to ED admission, which the authors speculated to be related to less timely care. 9 Similarly, a study of unscheduled adult hospitalizations found that patients admitted directly had higher mortality for time-sensitive conditions such as acute myocardial infarction and sepsis than patients admitted through EDs, differences not observed among adults admitted with pneumonia, asthma, cellulitis, and several other common, yet frequently less emergent, reasons for hospitalization.…”