Comparing Outcomes Between Direct and ED Admissions for Neonatal Hyperbilirubinemia.

OBJECTIVES: Pediatric direct admissions (DA) have multiple benefits including reduced emergency department (ED) volumes, greater patient and provider satisfaction, and decreased costs without compromising patient safety. We sought to compare resource utilization and outcomes between patients with a primary diagnosis of neonatal hyperbilirubinemia directly admitted with those admitted from the ED. METHODS: Single-center, retrospective study at a large, academic, free-standing children's hospital (2017-2021). Patients were between 24 hours and 14 days old with a gestational age of ≥35 weeks, admitted with a primary diagnosis of neonatal hyperbilirubinemia. Outcomes included length of stay (LOS), time to clinical care, resource utilization, NICU transfer, and 7-day readmission for phototherapy. RESULTS: A total of 1098 patients were included, with 276 (25.1%) ED admissions and 822 (74.9%) DAs. DAs experienced a shorter median time to bilirubin level collection (1.9 vs 2.1 hours, P = .003), received less intravenous fluids (8.9% vs 51.4%, P < .001), had less bilirubin levels collected (median of 3.0 vs 4.0, P < .001), received phototherapy sooner (median of 0.8 vs 4.2 hours, P < .001), and had a shorter LOS (median of 21 vs 23 hours, P = .002). One patient who was directly admitted required transfer to the NICU. No differences were observed in the 7-day readmission rates for phototherapy. CONCLUSIONS: Directly admitting patients for the management of neonatal hyperbilirubinemia is a preferred alternative to ED admission as our study demonstrated that DAs had a shorter time to clinical care, shorter LOS, and less unnecessary resource utilization with no difference in 7-day readmissions for phototherapy.

Effectiveness of Direct Admission Compared to Admission Through the Emergency Department: A Stepped-Wedge Cluster-Randomized Trial.

OBJECTIVE: Direct admission (DA) to hospital can reduce emergency department (ED) utilization by bypassing the ED during the admission process. We implemented a DA program across 3 health systems and compared timeliness of care, family experience of care, and post-admission clinical deterioration among children admitted via DA versus the ED after their clinic was randomized to begin the DA program. METHODS: Using a stepped-wedge design, 69 primary and urgent care clinics were randomized to 1 of 4 time points to begin a voluntary DA program, February 1, 2020 to April 30, 2023. Outcomes in children <18 years admitted with 7 common medical diagnoses were compared using adjusted logistic or linear regression. RESULTS: A total of 2599 children were admitted with eligible diagnoses during the study period , including 145 children admitted directly and 1852 admitted through EDs after program implementation at their clinic. Median age was 2.8 (interquartile range: 1.1-6.8) years, 994 (49.8%) were female, and 1324 (66.3%) were Medicaid-insured. Adjusted regression analyses showed that if each child was admitted via DA versus the ED, average time to initial clinical assessment was 3.1 minute (95% confidence interval: 1.7-4.5) slower, whereas time to initial therapeutic management was 49.6 minutes faster on average (95% confidence interval: 30.3.2-68.9). There were no significant differences in time to initial diagnostic testing or rates of post-admission clinical deterioration. CONCLUSIONS: Compared with ED admission, DA appears equally safe and acceptable to families, and may be associated with a significantly shorter time to initial therapeutic management with modestly longer time to initial clinical assessment.