Original Contribution
A reduction in hospitalization, length of stay, and hospital charges for croup with the institution of a pediatric observation unit

https://doi.org/10.1016/j.ajem.2006.05.003Get rights and content

Abstract

Objectives

The aim of the study was to assess the impact of an observation unit (OU) on hospital resource utilization for patients with croup.

Methods

A retrospective review with the use of a historical control was performed for 2 years of nondischargeable emergency department (ED) patients with croup.

Results

The total number of ED patients with croup was 694 in the first year and 789 in the second year. Hundred seventy patients were enrolled, 66 in the first year and 104 in the second year (76 admitted to the OU and 33 admitted to the ward). There was a reduction in the ward admission rate from 9.5% to 4.2% (P < .0001) from the first to the second year. The median length of stay for the pre-OU group was 27.2 vs 21.3 hours for the post-OU group (P = .03). The median charge for the pre-OU group was $1685 vs $1327 for the post-OU group (P = .03).

Conclusions

After the introduction of the OU, hospitalization was reduced, and the overall resource utilization for the care of nondischargeable ED patients with croup was reduced.

Introduction

Observation units (OUs) in emergency departments (EDs) are designed to accommodate patients whose stay is expected to be less than 23 hours but longer than the traditional ED course. Some authors believe that by using OUs certain inpatient admissions may be avoided, while still maintaining a high quality of care [1]. Certain adult studies have shown that the use of OUs may improve diagnostic accuracy in certain disease processes, such as patients with abdominal pain [2].

A few specific illnesses, asthma and abdominal pain, have been formally studied with regard to their treatment in a pediatric OU [1], [2], [3]. Scribano et al evaluated the use of an OU by pediatric ED physicians for common pediatric illnesses, including croup, asthma, enteritis/dehydration, poisonings, and seizures. Patients with croup in that study were twice as likely to be admitted to the OU vs the inpatient unit. In addition, only 9% of patients with croup initially admitted to the OU required subsequent transfer to the inpatient unit [1].

Studies show that most patients with croup are treated as outpatients, only a small percentage of patients with croup require admission to the hospital, and most of these admissions have short hospital stays [4], [5]. Marx et al [4] reports that the proportion of children hospitalized with croup after being evaluated in a pediatric practices ranges from 1.3% to 5.6%. Other reports also suggest a low admission rate for croup [5].

No previously published studies directly evaluate OUs for the management of croup. Although Scribano et al [1] studied patients with croup in a pediatric OU setting, these patients were only a small subset of the study population. We therefore sought to describe our experience with a larger number of patients, specifically those with croup, in an OU. We hypothesized that the OU would reduce hospitalization for patients with croup. We further hypothesized that the introduction of the OU would reduce the overall resource utilization for the care of nondischargeable ED patients with croup. Although the intent of this study was not to demonstrate patient safety, other studies have shown that only a small percentage of patients with croup cared for in an OU require subsequent hospital admission [1].

Section snippets

Materials and methods

Our study was a retrospective review of nondischargeable ED patients with croup. Our research design used a historical control group for comparison. The study took place during a 2-year period (August 1998–August 2000) at a tertiary care pediatric hospital, Primary Children's Medical Center (Salt Lake City, Utah). The ED at Primary Children's Medical Center has approximately 43 000 pediatric visits per year with a general admission rate of 20%. The OU, specifically named the Rapid Treatment

Results

A total of 1483 patients with croup were seen in the ED during the 2-year study period. There were 694 patients in the first or pre-OU year and 789 patients in the second or post-OU year. Patients that were discharged home from the ED were excluded from the study. Patients that were admitted to the PICU were also excluded from the study. The remaining 170 patients make up our study population of nondischargeable ED patients with croup.

In the pre-OU year, 66 (9.5%) of 694 patients were admitted

Discussion

Observation units in EDs provide an alternative to inpatient admissions in certain clinical scenarios. Although seeking improved resource utilization is important during the entire year, this can be of particular importance during busy respiratory seasons when many pediatric hospitals have a full inpatient census. The use of OUs may improve the efficiency in a health care system of limited resources.

There are limited data regarding the overall effectiveness of OUs in pediatrics, and only a few

References (8)

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Presented at the Society for Academic Emergency Medicine, May 2001.

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