Ir J Med Sci DOI 10.1007/s11845-014-1222-0
BRIEF REPORT
Emergency review clinic: impact on paediatric admissions B. Rai • F. McCartan • S. Moka • F. Sharif
Received: 21 September 2014 / Accepted: 27 October 2014 Ó Royal Academy of Medicine in Ireland 2014
Abstract Background Inappropriate or unnecessary paediatric inpatient admissions are sometimes unavoidable but are costly and increase pressure on services. Various measures, including paediatric observation units, have been undertaken in an attempt to reduce these admissions. Aims We established an emergency review clinic to assess whether we could reduce admission rates by giving carefully selected children follow-up ED review appointments. Methods An emergency review clinic was run in the paediatric room of the Emergency Department by a senior paediatric registrar during the hours 10 a.m. to 12 midday, Monday to Friday inclusive. Patients were booked into this review clinic from ED. Data relating to paediatric admissions in the years prior to and after the institution of the review clinic were analysed. Results A significant reduction (p \ 0.0001) was noted in the paediatric inpatient admission rates following establishment of the review clinic.
B. Rai (&) F. McCartan S. Moka F. Sharif Department of Pediatrics, Midland Regional Hospital, Mullingar, Ireland e-mail: [email protected] F. McCartan e-mail: [email protected] S. Moka e-mail: [email protected] F. Sharif e-mail: [email protected] F. Sharif Royal College of Surgeons (RCSI), Dublin 2, Ireland
Conclusions A paediatric emergency review clinic can significantly reduce unnecessary or inappropriate admissions but more research is needed to quantitatively characterise parent/patient satisfaction in this regard. Keywords Pediatrics Emergency department Pediatric admissions
Introduction Decision regarding admission to the Paediatric ward from Paediatric Emergency Department (ED) is adjudged by the medical condition and clinical status of the concerned child but also to some extent, by physician uncertainty, caregiver’s concern and the capacity to manage the condition in a home setting. The emergency admission rate for children under 15 in the England increased by 28 % between 1997 and 2006 [1]. Inappropriate or unnecessary admissions from emergency department not only increase the healthcare delivery costs of the state but also impair the quality of services delivered to the patients due to increased load on healthcare staff. Paediatric observation units have been established in an attempt to reduce admissions and have had favourable reviews but these units require a significant healthcare staff allocation. We set up an emergency review clinic for those patients who may, in the absence of such a clinic, have been admitted on the basis of need for observation of illness trajectory, significant parental anxiety or difficult social circumstances. We noted a significant decline in the Paediatric ward admission rates after institution of such a clinic. This is a unique study looking at the effectiveness of a paediatric emergency review clinic.
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Ir J Med Sci
Methods A retrospective review, with use of historical control group, was undertaken to assess the effectiveness of a paediatric emergency review clinic in the Midlands Regional Hospital, Mullingar, Ireland. Prior to 2012, all children attending ED with medical conditions were first assessed by an SHO (either a paediatric or a GP trainee) who had support from a registrar in-house and a consultant on call. These children were admitted, discharged to the care of their GP or referred to an out-patient clinic. In 2012, a senior paediatric non-consultant hospital doctor (NCHD) was appointed to the ED and an Emergency Review clinic was established with the aim of reviewing children who did not require acute hospitalisation but who could benefit from short-term follow-up to assess their medical condition/progress, These patients were given an appointment to return to the review clinic after a first ED consultation. The senior registrar reviewed the children in the generally quieter morning hours from Monday to Friday in the ED department. A maximum of five patients were booked for review on any 1 day as the clinic ran concurrently with the ED accepting GP referrals, self-referrals and emergencies. The time interval from first visit to review appointment was based on the severity of the condition, time needed to see results from treatment and parental coping attitude towards the illness. Such time intervals varied from 1 day up to 4 weeks. Data relating to the review clinic was stored both in handwritten diary and in patient electronic data recording system. For the purpose of study, review clinic data were collected from February 2012 to January 2014. Control data was collected from February 2010 to January 2012 for comparison. Statistical analysis was done using Chi-square test with Yates correction.
Neurological symptoms (81 patients), musculoskeletal complaints (104 patients), renal issues (60 patients) and miscellaneous, including repeat blood tests and feeding issues (352 patients) were among the reasons for attendance at the review clinic. Admissions from the ED to paediatric ward was 4,053 (average 5.55 per day) prior to the start of review clinic. 3,095 patients (average 4.23 per day) were admitted during the next 2 years period while review clinic was running (Fig. 1). A significant reduction was noted in the pediatric admission after institution of review clinic (two tailed p \ 0.0001, Chi-squared equals 633.583 with 1 degree of freedom). Beside this, the cost of hospital was saved by an average of 0.25 million euros per year after cutting down on these admissions.
Discussion Inappropriate paediatric inpatient admissions have attracted researcher’s attention from time to time with various investigative tools and remedial steps suggested in the literature to date [2]. Very few hospitals use paediatric observation units to monitor patients because of the increased manpower and extra resources such units demand [3]. The British Association for Accidents and Emergency recommends short-stay beds for every Emergency department to reduce ward admissions [4]. A systematic review stated that acute paediatric assessment services are a safe, efficient, and acceptable alternative to inpatient admission pending further consolidation of the same by more research [5]. Pediatric patients are different than adults in being dependent on caregivers for most of their medical care process. Caregiver’s anxiety and understanding of paediatric illness varies and plays an important role in physician’s assessment decisions and ongoing care of their
Results Total 20,980 patients visited ED in 4 years from February 2010 to January 2014. 9,373 and 11,607 patients visited in the 2 years period prior to and after the start of review clinic, respectively. 1,106 patients (73.34 %) of the 1,561 total booked, attended review clinic during the 2-year period from February 2012 to January 2014. 22 (1.45 %) booked patients attended earlier than scheduled review clinical visits and 18 of these children were admitted. Of 1,106 patients who attended review clinic 21 eventually were referred to outpatient clinics due to ongoing issues or the need of further follow-up. Respiratory illnesses (202 of 1,106) and gastrointestinal problems (280 of 1,106) were amongst the most frequent reasons for referral to the review clinic. Cardiovascular symptoms (27 patients),
123
Fig. 1 Bar diagram showing number of children visiting ED and concurrent admissions pre (2010–2012) and post (2012–2014) instituition of ED Review clinic
Ir J Med Sci
patients. Children attend paediatric ED with a variety of conditions, both acute and chronic. Some acute conditions can be managed on an ambulatory basis and some chronic conditions are more appropriately referred to out-patient clinics but GPs may use the ED route because of long waiting times for clinic appointments, dissatisfaction with treatment results to date and pressure from caregivers for a second opinion. Caregivers present directly to the secondary care setting when concerned or dissatisfied. A review clinic was established in Midland Regional Hospital, Mullingar to provide ambulatory care and short-term follow-up for selected conditions with rewarding results. There had been a reduction in the inpatient admission rate and caregivers were generally happy that follow-up within 1-month was organised. The option of review not only helped ease caregiver’s anxiety but also allowed doctors to reassess the course of disease or treatment. Bianco et al. [6] suggested more vigilant interaction between hospital and community-based primary care services to mitigate inappropriate admissions. Liaison with primary care providers had improved following establishment of our review clinic as update or discharge letters were generally sent following review. We conclude that our emergency review clinic has had a significant impact in reducing paediatric emergency admission rates and it is cost effective. Anecdotal evidence
points to patient/caregiver satisfaction with the option of short-term review by a senior paediatric doctor in the clinic setting, but further research is required for quantitative measurement. Conflict of interest
None.
References 1. Gill PJ, Goldacre MJ, Mant D et al (2013) Increase in emergency admissions to hospital for children aged under 15 in England, 1999–2010: national database analysis. Arch Dis Child 98(5):328–334. doi:10.1136/archdischild-2012-302383 2. Waldrop R, Peck GQ, Hutchinson S, Randall Z (1998) Comparison of pediatric hospitalization using the pediatric appropriateness evaluation protocol at three diverse hospitals in Louisiana. J La State Med Soc 150(5):211–217 3. Levett I, Berry K, Wacogne I (2006) Review of a paediatric emergency department observation unit. Emerg Med J 23:612–613 4. British Association of Accident and Emergency Medicine (1989) Recommendations for accident and emergency wards. BAEM, London 5. Ogilvie D (2005) Hospital based alternatives to acute paediatric admission: a systematic review. Arch Dis Child 90(2):138–142 6. Bianco A, Pileggi C, Trani F, Angelillo IF (2003) Appropriateness of admissions and days of stay in pediatric wards of Italy. Pediatrics 112(1 Pt 1):124–128
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BRIEF REPORT
Emergency review clinic: impact on paediatric admissions B. Rai • F. McCartan • S. Moka • F. Sharif
Received: 21 September 2014 / Accepted: 27 October 2014 Ó Royal Academy of Medicine in Ireland 2014
Abstract Background Inappropriate or unnecessary paediatric inpatient admissions are sometimes unavoidable but are costly and increase pressure on services. Various measures, including paediatric observation units, have been undertaken in an attempt to reduce these admissions. Aims We established an emergency review clinic to assess whether we could reduce admission rates by giving carefully selected children follow-up ED review appointments. Methods An emergency review clinic was run in the paediatric room of the Emergency Department by a senior paediatric registrar during the hours 10 a.m. to 12 midday, Monday to Friday inclusive. Patients were booked into this review clinic from ED. Data relating to paediatric admissions in the years prior to and after the institution of the review clinic were analysed. Results A significant reduction (p \ 0.0001) was noted in the paediatric inpatient admission rates following establishment of the review clinic.
B. Rai (&) F. McCartan S. Moka F. Sharif Department of Pediatrics, Midland Regional Hospital, Mullingar, Ireland e-mail: [email protected] F. McCartan e-mail: [email protected] S. Moka e-mail: [email protected] F. Sharif e-mail: [email protected] F. Sharif Royal College of Surgeons (RCSI), Dublin 2, Ireland
Conclusions A paediatric emergency review clinic can significantly reduce unnecessary or inappropriate admissions but more research is needed to quantitatively characterise parent/patient satisfaction in this regard. Keywords Pediatrics Emergency department Pediatric admissions
Introduction Decision regarding admission to the Paediatric ward from Paediatric Emergency Department (ED) is adjudged by the medical condition and clinical status of the concerned child but also to some extent, by physician uncertainty, caregiver’s concern and the capacity to manage the condition in a home setting. The emergency admission rate for children under 15 in the England increased by 28 % between 1997 and 2006 [1]. Inappropriate or unnecessary admissions from emergency department not only increase the healthcare delivery costs of the state but also impair the quality of services delivered to the patients due to increased load on healthcare staff. Paediatric observation units have been established in an attempt to reduce admissions and have had favourable reviews but these units require a significant healthcare staff allocation. We set up an emergency review clinic for those patients who may, in the absence of such a clinic, have been admitted on the basis of need for observation of illness trajectory, significant parental anxiety or difficult social circumstances. We noted a significant decline in the Paediatric ward admission rates after institution of such a clinic. This is a unique study looking at the effectiveness of a paediatric emergency review clinic.
123
Ir J Med Sci
Methods A retrospective review, with use of historical control group, was undertaken to assess the effectiveness of a paediatric emergency review clinic in the Midlands Regional Hospital, Mullingar, Ireland. Prior to 2012, all children attending ED with medical conditions were first assessed by an SHO (either a paediatric or a GP trainee) who had support from a registrar in-house and a consultant on call. These children were admitted, discharged to the care of their GP or referred to an out-patient clinic. In 2012, a senior paediatric non-consultant hospital doctor (NCHD) was appointed to the ED and an Emergency Review clinic was established with the aim of reviewing children who did not require acute hospitalisation but who could benefit from short-term follow-up to assess their medical condition/progress, These patients were given an appointment to return to the review clinic after a first ED consultation. The senior registrar reviewed the children in the generally quieter morning hours from Monday to Friday in the ED department. A maximum of five patients were booked for review on any 1 day as the clinic ran concurrently with the ED accepting GP referrals, self-referrals and emergencies. The time interval from first visit to review appointment was based on the severity of the condition, time needed to see results from treatment and parental coping attitude towards the illness. Such time intervals varied from 1 day up to 4 weeks. Data relating to the review clinic was stored both in handwritten diary and in patient electronic data recording system. For the purpose of study, review clinic data were collected from February 2012 to January 2014. Control data was collected from February 2010 to January 2012 for comparison. Statistical analysis was done using Chi-square test with Yates correction.
Neurological symptoms (81 patients), musculoskeletal complaints (104 patients), renal issues (60 patients) and miscellaneous, including repeat blood tests and feeding issues (352 patients) were among the reasons for attendance at the review clinic. Admissions from the ED to paediatric ward was 4,053 (average 5.55 per day) prior to the start of review clinic. 3,095 patients (average 4.23 per day) were admitted during the next 2 years period while review clinic was running (Fig. 1). A significant reduction was noted in the pediatric admission after institution of review clinic (two tailed p \ 0.0001, Chi-squared equals 633.583 with 1 degree of freedom). Beside this, the cost of hospital was saved by an average of 0.25 million euros per year after cutting down on these admissions.
Discussion Inappropriate paediatric inpatient admissions have attracted researcher’s attention from time to time with various investigative tools and remedial steps suggested in the literature to date [2]. Very few hospitals use paediatric observation units to monitor patients because of the increased manpower and extra resources such units demand [3]. The British Association for Accidents and Emergency recommends short-stay beds for every Emergency department to reduce ward admissions [4]. A systematic review stated that acute paediatric assessment services are a safe, efficient, and acceptable alternative to inpatient admission pending further consolidation of the same by more research [5]. Pediatric patients are different than adults in being dependent on caregivers for most of their medical care process. Caregiver’s anxiety and understanding of paediatric illness varies and plays an important role in physician’s assessment decisions and ongoing care of their
Results Total 20,980 patients visited ED in 4 years from February 2010 to January 2014. 9,373 and 11,607 patients visited in the 2 years period prior to and after the start of review clinic, respectively. 1,106 patients (73.34 %) of the 1,561 total booked, attended review clinic during the 2-year period from February 2012 to January 2014. 22 (1.45 %) booked patients attended earlier than scheduled review clinical visits and 18 of these children were admitted. Of 1,106 patients who attended review clinic 21 eventually were referred to outpatient clinics due to ongoing issues or the need of further follow-up. Respiratory illnesses (202 of 1,106) and gastrointestinal problems (280 of 1,106) were amongst the most frequent reasons for referral to the review clinic. Cardiovascular symptoms (27 patients),
123
Fig. 1 Bar diagram showing number of children visiting ED and concurrent admissions pre (2010–2012) and post (2012–2014) instituition of ED Review clinic
Ir J Med Sci
patients. Children attend paediatric ED with a variety of conditions, both acute and chronic. Some acute conditions can be managed on an ambulatory basis and some chronic conditions are more appropriately referred to out-patient clinics but GPs may use the ED route because of long waiting times for clinic appointments, dissatisfaction with treatment results to date and pressure from caregivers for a second opinion. Caregivers present directly to the secondary care setting when concerned or dissatisfied. A review clinic was established in Midland Regional Hospital, Mullingar to provide ambulatory care and short-term follow-up for selected conditions with rewarding results. There had been a reduction in the inpatient admission rate and caregivers were generally happy that follow-up within 1-month was organised. The option of review not only helped ease caregiver’s anxiety but also allowed doctors to reassess the course of disease or treatment. Bianco et al. [6] suggested more vigilant interaction between hospital and community-based primary care services to mitigate inappropriate admissions. Liaison with primary care providers had improved following establishment of our review clinic as update or discharge letters were generally sent following review. We conclude that our emergency review clinic has had a significant impact in reducing paediatric emergency admission rates and it is cost effective. Anecdotal evidence
points to patient/caregiver satisfaction with the option of short-term review by a senior paediatric doctor in the clinic setting, but further research is required for quantitative measurement. Conflict of interest
None.
References 1. Gill PJ, Goldacre MJ, Mant D et al (2013) Increase in emergency admissions to hospital for children aged under 15 in England, 1999–2010: national database analysis. Arch Dis Child 98(5):328–334. doi:10.1136/archdischild-2012-302383 2. Waldrop R, Peck GQ, Hutchinson S, Randall Z (1998) Comparison of pediatric hospitalization using the pediatric appropriateness evaluation protocol at three diverse hospitals in Louisiana. J La State Med Soc 150(5):211–217 3. Levett I, Berry K, Wacogne I (2006) Review of a paediatric emergency department observation unit. Emerg Med J 23:612–613 4. British Association of Accident and Emergency Medicine (1989) Recommendations for accident and emergency wards. BAEM, London 5. Ogilvie D (2005) Hospital based alternatives to acute paediatric admission: a systematic review. Arch Dis Child 90(2):138–142 6. Bianco A, Pileggi C, Trani F, Angelillo IF (2003) Appropriateness of admissions and days of stay in pediatric wards of Italy. Pediatrics 112(1 Pt 1):124–128
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