Pediatric observation units in the United States: A systematic review

Abstract

BACKGROUND: As more efficient and value‐based care models are sought for the US healthcare system, geographically distinct observation units (OUs) may become an integral part of hospital‐based care for children. PURPOSE: To systematically review the literature and evaluate the structure and function of pediatric OUs in the United States. DATA SOURCES: Searches were conducted in Medline, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Health Care Advisory Board (HCAB), Lexis‐Nexis, National Guideline Clearinghouse, and Cochrane Reviews, through February 2009, with review of select bibliographies. STUDY SELECTION: English language peer‐reviewed publications on pediatric OU care in the United States. DATA EXTRACTION: Two authors independently determined study eligibility. Studies were graded using a 5‐level quality assessment tool. Data were extracted using a standardized form. DATA SYNTHESIS: A total of 21 studies met inclusion criteria: 2 randomized trials, 2 prospective observational, 12 retrospective cohort, 2 before and after, and 3 descriptive studies. Studies present data on more than 22,000 children cared for in OUs, most at large academic centers. This systematic review provides a descriptive overview of the structure and function of pediatric OUs in the United States. Despite seemingly straightforward outcomes for OU care, significant heterogeneity in the reporting of length of stay, admission rates, return visit rates, and costs precluded our ability to conduct meta‐analyses. We propose standard outcome measures and future directions for pediatric OU research. CONCLUSIONS: Future research using consistent outcome measures will be critical to determining whether OUs can improve the quality and cost of providing care to children requiring observation‐length stays. Journal of Hospital Medicine 2010;5:172–182. © 2010 Society of Hospital Medicine.

Trends in Observation‐prone Emergency Department Visits Among Michigan Children, 2007–2011

“…3 We hypothesized an increase in observation charge code utilization over time and variation in the application of observation charge codes across hospital types.…”

“…8 Several single-center studies suggest that children with select diagnoses can be treated effectively in pediatric observation units with potential for shorter length of stay and costs savings. 3 Yet pediatric observation units are present in 39% of freestanding children's hospitals, 7 39% of hospitals with separate pediatric wards, 9 and just 4% of hospitals without pediatric wards. 9 Our results indicate a growing population of pediatric ED patients who may benefit from the development of cost-effective alternatives to inpatient care that draw on the principals of observation medicine.…”

“…The ICD-9-CM codes were chosen to be representative of conditions that are commonly admitted under observation status 2 and have been successfully treated in physically distinct pediatric observation units, 3 including allergic reaction, cellulitis, dehydration, diabetic ketoacidosis, head injury, headache, ingestion, respiratory conditions, and seizure. Continuous enrollment for the 90 days before and after an ED visit was required for study eligibility.…”

Pediatric observation status: Are we overlooking a growing population in children's hospitals?

“…21 While we were not able to determine the location of care for observation status patients in this study, we know that few children's hospitals have dedicated observation units and, even when an observation unit is present, not * Adjusted for severity using SCS score, clustering by hospital, and grouped treatment variable. † Significant at the P < 0.05 level.Abbreviations: AOR, adjusted odds ratio; CI, confidence interval; DGS, Diagnosis Grouping System; GI, gastrointestinal; NE, non-estimable due to small sample size; SCS, severity classification system.…”

The Development and Implementation of a Direct Admission System at a Tertiary Care Hospital

“…8,9 Patients in the ED awaiting admission reduce overall ED throughput. 10,11 This is being addressed in a variety of ways, including streamlining admission procedures with the creation of innovative admission protocols 12,13 and new hospital units such as observation units 14,15 and "fast-track" units. 16,17 However, there is a paucity of literature describing the development and use of a process to improve patient fl ow in the ED by the direct admission of patients to the inpatient setting, bypassing the ED entirely.…”