Characteristics of Admissions from the Pediatric Emergency Department Observation Unit.

OBJECTIVE: Emergency department observation units (EDOUs) are used to manage common pediatric illnesses and reduce the admission rate to the hospital. Most of these patients require a short duration of observation before a determination can be made whether they need to be admitted to the hospital or safely discharged home. The purpose of this study was to determine the characteristics of admissions from a pediatric EDOU for the top 10 diagnoses admitted to the unit. This will help standardize the disposition of such types of patients from the ED, hence improving the efficiency of the unit. METHODS: We did a retrospective surveillance study of admitted patients from 0 to 18 years of age from the EDOU for the top 10 diagnoses. Descriptive data were reported using percentages and medians with interquartile ranges. Pearson χ2 tests were used to determine significant differences (P < 0.05) between the reason for admission and medical history. RESULTS: In total, 520 patients were admitted from the EDOU during the study period. The median patient age was 3.39 years, with most being Hispanic and female. The top three primary diagnoses of all admitted patients were cellulitis and abscess, gastroenteritis, and bronchiolitis. Sixty-three percent of all admitted patients had secondary diagnoses. Most of these patients were admitted to the inpatient unit due to progression of the primary condition. CONCLUSIONS: The characteristics of admissions from the EDOU may help us to understand historical experience regarding diagnoses, timing, and indications of deterioration, resource utilization, and other metrics that resulted in transfers of EDOU patients to the intensive care unit/operating room/inpatient units.

Comparing nasal suction devices in children with bronchiolitis: A pilot randomized control trial.

BACKGROUND/OBJECTIVES: Bronchiolitis is the most common cause of lower respiratory tract infections that lead to hospitalizations in infants and young children. METHODS: In this randomized controlled pilot study, we compared two separate nasal suction devices, namely the over counter device by the brand name of NoseFrida and the standard hospital device NeoSucker, in hospitalized children with bronchiolitis to assess equivalence of length of stay within a ± 5-h equivalence margin and to compare readmission rates and associated complications. Additionally, parental satisfaction for the NoseFrida device was measured with a six question (5-point Likert scale) survey. RESULTS: There were 20 patients randomized to the NeoSucker group and 24 randomized to the NoseFrida group. The mean length of stay for the NoseFrida group was 33.5 ± 25.4 h compared to 31.0 ± 15.6 h in the NeoSucker group, which did not establish equivalence within the ±5-h equivalence margin (p = 0.352). Parents were generally satisfied with the NoseFrida. Patients treated with the two devices had similar frequencies of deep suctioning and readmission within 48 h. CONCLUSIONS: Although the mean length of stay was comparable for bronchiolitis patients treated with the NoseFrida and NeoSucker, the relatively small sample size and large amount of variability precluded demonstrating equivalence. Since this was a pilot, further studies are needed to evaluate the recommendation for the use of such devices in both the hospital setting and in the outpatient management of bronchiolitis.

Managing Skin and Soft Tissue Infections in the Emergency Department Observation Unit.

BACKGROUND: Skin and soft tissue infections (SSTIs) are a common reason for presentation to the emergency department (ED) and account for 3% of ED visits. Patients with a diagnosis of cellulitis requiring intravenous (IV) antibiotics have traditionally been admitted to the hospital. In our institution, these patients are placed in the ED Observation Unit (EDOU) for IV antibiotics. OBJECTIVES: The purpose of this study is to determine if 3 doses of IV antibiotics are adequate to document clinical improvement in children with uncomplicated SSTI. METHODS: A prospective cohort study of children aged 3 months to 18 years with uncomplicated SSTI admitted (2009-2013) to the EDOU at a children's hospital for IV antibiotics was conducted. RESULTS: One hundred six patients (mean age, 68 months) were enrolled; 57% were boys, 53% of patients had cellulitis only and 47% had cellulitis with drained abscesses. There was a significant decrease in pain scores and size of cellulitis from arrival to discharge (P < 0.001 and P < 0.001, respectively). Eighty-three percent of patients were discharged after 3 to 4 doses of antibiotics, and 17% were admitted. The location of the wound, presence of systemic symptoms, and prior use of oral antibiotics did not predict admission in our study. CONCLUSIONS: The EDOU is a reasonable alternative to inpatient admission in the management of patients with uncomplicated SSTI requiring IV antibiotics.

Risk factors for admission in children with bronchiolitis from pediatric emergency department observation unit.

BACKGROUND: Patients with bronchiolitis are increasingly being admitted to emergency department observation units (EDOUs) but often require subsequent hospitalization. To better identify ED patients who should be directly admitted to the hospital rather than the EDOU, the predictors of admission must be identified. OBJECTIVES: The objective of this study was to determine the predictors of subsequent hospital admission from the EDOU in infants and young children with bronchiolitis. METHOD: This was a retrospective cohort study of patients younger than 2 years admitted to an EDOU with bronchiolitis between April 1, 2003, and March 31, 2007. Univariate analysis was followed by logistic regression to identify the significant predictors of hospital admission from the EDOU. RESULTS: There were 325 patients in the study: 67% were younger than 6 months, and 60% were male. Eighty-five (26%) were admitted to the hospital from the EDOU. Predictors for admission from the EDOU included parental report of poor feeding or increased work of breathing, oxygen saturation less than 93%, or ED treatment with racemic epinephrine (Vaponephrine) and intravenous fluids (IVFs). CONCLUSION: Patients with a history of increased work of breathing or oxygen saturation less than 93% and ED treatment with IVFs are at high risk for admission from the EDOU to the hospital. Direct admission to the hospital from the ED should be considered for these patients, particularly patients treated with IVFs and having an oxygen saturation less than 93% in the ED.

Managing well-appearing neonates with hyperbilirubinemia in the emergency department observation unit.

BACKGROUND: In September 2005, Texas Children's Hospital initiated a protocol for all neonates presenting to the emergency department (ED) with hyperbilirubinemia based on the American Academy of Pediatrics guidelines. As part of the protocol, low-risk neonates with hyperbilirubinemia requiring phototherapy are treated in the ED observation unit (EDOU). OBJECTIVE: The aim of the study was to compare time to phototherapy and duration of hospital stay in low-risk neonates with hyperbilirubinemia presenting to the Texas Children's Hospital ED before and after the initiation of a triage-based protocol. DESIGN/METHODS: We performed a retrospective historical control study comparing neonates with hyperbilirubinemia treated in the EDOU between January 1 and December 31, 2006 (EDOU group), with neonates with hyperbilirubinemia admitted to the inpatient unit between January 1 and December 31, 2004 (inpatient group). RESULTS: There were 167 neonates included in the study: 62 neonates were treated in the EDOU and 105 in the inpatient unit. Median time to phototherapy (inpatient: 6.7 hours, EDOU: 1.6 hours) and duration of hospital stay (inpatient: 41.8 hours, EDOU: 17.8 hours) were shorter for neonates treated in the EDOU compared with neonates treated in the inpatient unit. Of the neonates treated in the EDOU initially, 11 were admitted to the inpatient unit after 24 hours because their bilirubin level did not decline adequately. CONCLUSIONS: Low-risk neonates with hyperbilirubinemia can be managed more efficiently in an EDOU than in an inpatient unit. Phototherapy is initiated more rapidly, and patients are discharged sooner in the EDOU than in the inpatient setting.