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Management
The treatment of HG is primarily supportive with
intravenous fluids and antiemetics.
7,8,9
A proposed regimen for patients who are admitted to
the OU with HG includes:
1) Vitamin B-6 (pyridoxine) IV 10–25 mg daily
2) Metoclopramide 10 mg IV, IM or orally q 6 h
(pregnancy class B)
3) Promethazine 12.5–25 mg IV, q 4–6h
(pregnancy class C)
4) Ondansetron 4–8 mg IV or orally q 6 h
(pregnancy class B)
Steroids may be used in patients refractory to
standard therapy.
9,10
It is important to use steroids
cautiously and only in extremely refractory cases as
they can increase the risk for oral clefts in the first
10 weeks of gestation.
10
However, if using methylprednisolone, the patient will most likely require
inpatient stay and not OU admission. Thus, the use
of methylprednisolone should be reserved for the
inpatient setting (not the OU) with administration
as ordered by the obstetrician.
Vitamin B6 has been found to reduce nausea
and vomiting when compared with placebo.
1
Ondansetron, a serotonin-receptor antagonist,
showed no benefit over promethazine, except for
being more expensive.
1
Promethazine was compared with methylprednisolone in a randomized,
double-blind, controlled trial. Methylprednisolone appeared to decrease the rate of readmission
for HG. However, patients randomized to promethazine had a significantly longer duration of
symptoms prior to treatment.
10
If electrolyte abnormalities occur, these can
be treated in the OU. If persistent dehydration,
electrolyte loss, and/or weight loss occur despite
aggressive therapy, then inpatient admission is
indicated.
Conclusion
Hyperemesis gravidarum is generally self-limited
and, in most cases, improves by the end of the
first trimester. The majority of these patients can
be successfully managed in the OU setting.
References
1. ACOG. American College of
Obstetrics and Gynecology
Practice Bulletin: nausea and
vomiting of pregnancy. Obstet
Gynecol. 2004;103(4):803–814.
2. Lacroix R, Eason E, Melzack R.
Nausea and vomiting during
pregnancy: a prospective study
of its frequency, intensity,
and patterns of change. Am
J Obstet Gynecol. 2000; 182
(4):931–937.
3. Bailit JL. Hyperemesis
gravidarium: epidemiologic
findings from a large cohort.
Am J Obstet Gynecol. 2005; 193
(3 Pt 1):811–814.
4. Fell DB, Dodds L, Joseph KS,
et al. Risk factors for
hyperemesis gravidarum
requiring hospital admission
during pregnancy. Obstet
Gynecol. 2006; 107(2 Pt 1):
277–284.
5. Dodds L, Fell DB, Joseph KS,
et al. Outcomes of pregnancies
complicated by hyperemesis
gravidarum. Obstet Gynecol.
2006; 107(2 Pt 1):285–292.
6. Holmgren C, Aagaard-Tillery
KM, Silver RM, et al.
Hyperemesis in pregnancy: an
evaluation of treatment
strategies with maternal and
neonatal outcomes. Am
J Obstet Gynecol 2008; 198
(1):56.e1–4.
7. Tan JY, Loh KC, Yeo GS, et al.
Transient hyperthyroidism
of hyperemesis gravidarum.
BJOG 2002; 109(6):
683–688.
8. Goodwin TM. Hyperemesis
gravidarum. Obstet Gynecol
Clin North Am. 2008; 35
(3):401–417, viii.
9. Matok I, Gorodischer R,
Koren G, et al. The safety of
metoclopramide use in the
first trimester of pregnancy.
N Engl J Med. 2009;
2528–2535.
10. Safari HR, Alsulyman OM,
Gherman RB, et al. Experience
with oral methylprednisolone
in the treatment of refractory
hyperemesis gravidarum.
Am J Obstet Gynecol. 1998; 178
(5):1054–1058.
Hyperemesis Gravidarum
056
21:15:16
Subpart IVK
Chapter
53
Clinical – Pediatrics and Geriatrics
Pediatric Observation Medicine
Sharon E. Mace, MD, FACEP, FAAP
Introduction
Pediatric patients comprise about 27% of all
emergency department (ED) visits.
1
There has
been a 60.4% increase in ED visits from 1991, in
which only 85 million patients were seen, to 2011,
when approximately 136.3 million patients were
evaluated in EDs, of which an estimated 36.8
million (27%) were infants and children.
2
There
is every indication that this exponential growth in
ED visits will continue. This growth along with
the increased acuity and complexity of patients,
3
and expanded ED evaluation are critical factors
leading to overcrowding in EDs, which has major
negative consequences including detrimental
effects on patient care and worse patient outcomes.
4
Moreover, overcrowding is not unique
to the United States, but is a worldwide problem.
5
Over the past few years, ED visits for pediatric
patients has also been increasing.
6
Infants under
12 months of age are the age group with the
highest annual per capita ED visit rate.
7
Pediatric
patients, like adults, also suffer from the harmful
impact of overcrowding.
8
Observation medicine (OM) has been suggested as a potential solution to this crisis and
has been successful has been in improving the
quality of patient care, increasing patient/family
satisfaction, decreasing missed diagnoses, creating
better risk management, decreasing inappropriate
hospital admissions, reducing length of stay
(LOS), and creating better patient outcomes,
while lowering costs.
9
This is true for pediatric
patients as well as adults.
10–12
Pathophysiology
Pediatric patients are, generally, more difficult
and complex to evalu ate than adults and at a
higher risk.
12,13
Infants and children often have
a nonspecific complaint and subtle physical examination findings. Preverbal children and infants
may be unable to communicate their symptoms.
Infants and children have an increased susceptibility to infection, limited physiologic reserve, and
developmental and/or age considerations. Diagnostic testing and therapeutic measures can have
unique considerations and challenges, ranging
from concerns over radiation exposure to the
difficulties in obtaining an intravenous line and/
or blood work or the need to perform sedation for
procedures, even simple radiology tests.
Although most pediatric patients evaluated in
the ED have a minor injury or mild illness or a
benign condition, the possibility of a serious
limb- or life- threatening illness/injury exists and
could be easily overlooked. Indeed, analysis of
malpractice awards confirms the fact that failure
to diagnose or a delay in diagnosis does happen,
often with disastrous consequences. Common
pediatric diagnoses including gastroenteritis and
appendicitis are repeatedly mentioned in malpractice lawsuits. Indeed, gastroenteritis is the
most frequent diagnosis in malpractice claims
and 15% of all malpractice dollars paid are for
missed appendicitis. Looking at cost per claim,
missed meningitis tops the list and at number
one accounts for 17% of all malpractice dollars
paid.
13
Physiologic, anatomic, and developmental
factors add to the complexity and risk in evaluating infants and children. Patients at the extremes
of age, including the very young, are known to
have an increased risk of infection, including both
a higher incidence and increased severity of infection, due to their lesser ability to fight infection.
Pediatric patients have a limited physiologic
reserve. For example, their greater body surface
area and lesser renal capacity to conserve water
and electrolytes increases their risk for dehydration, their proportionately greater head size predisposes them to head injury, their liver has a
reduced ability to detoxify substances, and they
057
21:15:31
rely on heart rate rather than stroke volume to
maintain their cardiac output.
There has also been an increase in individuals
with Special Health Care Needs (SHCN) and
many other high-risk pediatric patients (vulnerable population).
14
Such patients range from survivors of the intensive care units (whether the
Pediatric, Surgical, or Neonatal ICUs), oncology
patients (on chemotherapy, radiation therapy,
s/p bone marrow transplant), immunosuppressed
individuals (from medications, from disease such
as HIV, rheumatologic disorders, etc.) to the
transplant patients (kidney, liver, pancreas, lung,
heart) and those with chronic diseases (e.g., cystic
fibrosis and diabetes).
Such conditions add to the complexity and risk
of evaluating and managing pediatric patients,
especially infants and children.
The advantages of additional time for evaluation and treatment, with further diagnostic
testing and therapy, in these complex and highrisk infants and children are obvious. Moreover,
an observation stay may have another benefit in
pediatric patients. It has been suggested that the
observation of infants and children with repeat
examination may be preferred or at least equivalent to advanced diagnostic testing in some cases.
For example, serial examination of the stable
pediatric patient with right lower quadrant pain
and a nondiagnostic or poor quality ultrasound in
an observation unit (OU) may be preferable to
doing an abdominal CT scan, at least in terms of
avoiding radiation exposure with increased lifetime risks of malignancy.
15
Background
The first OUs evolved in the 1960s and includ ed
adults, while the first pediatric OUs or “Short
Stay Units” (SSUs) came into use in the 1970s.
Since then, there has been much literature
regarding the use of an observation stay for
adults, with diagnoses rangin g from heart failure,
asthma, transient ischemic attacks (TIAs) to syncope, and especially chest pain with the rapid
growth of chest pain units and even a Society of
Chest Pain Centers.
9
In spite of this early history, there has been a
relative paucity of information regarding pediatric
OM, along with the recognition that “there are not
many pediatric observation units, which in itself is
surprising considering their usefulness.”
16
The
first textbook of Observation Medicine by Graff
had 33 chapters, not one of which dealt with
pediatrics.
17
Moreover, of the limited literature
regarding pediatric OM, it almost exclusively
comes from tertiary care centers. This is in spite
of the fact that 81% of the infants and children
evaluated in EDs are seen in smaller community
hospitals
18
with combined adult and pediatric
EDs, which is likely an area for future growth
and research. (See pediatric OU patients in
Chapter 10 Observation Medicine in Community
Hospitals.)
The Principles of Pediatric
Observation Medicine
No matter what the age of the patient, the definition and key principles of OM are the same. OM
allows patients to undergo diagnostic evaluation
and/or treatment for a limited time frame, generally < 24 hours. An organizational framework
that provides for administrative oversight with
designated staffing and coverage, design, patient
accommodations, documentation requirements,
policies, procedures, protocols, order sets, care
paths, and performance improvement (PI) /continuous quality improvement (CQI)/metrics is
required for any OU.
9–12
(See Performance
Improvement, Chapter 9.)
Patients placed in observation status, whether
adult or pediatric, have the following inclusion
criteria: low risk, stable, low acuity, and/or low
severity, low-intensity nursing care, low-intensity
physician care, and non-intensive care. Criteria
for exclusion include critically ill, unstable, need
intensive nursing care, need intensive physician
care, and have an anticipated LOS > 24 hours.
(See Protocol Chapter 82.)
Differences between Pediatric and Adult
Observation Medicine: Design, Supplies,
Equipment, Medications
There are some differences between the adult and
pediatric OU. The supplies, equipment, and
medications may differ. The primary diagnoses
in the adult OU are cardiac: chest pain, heart
failure, syncope etc., while the top diagnoses in
the pediatric OU are respiratory (asthma, bronchiolitis, croup) and gastrointestinal (dehydration,
Pediatric Observation Medicine
057
21:15:31
gastroenteritis, vomiting, diarrhea, etc.)
12,19–21
(Table 53.1), which has implications for the need
for monitoring, equipment, procedures, and
medications.
The focus for the adult OU is repeat ECGs
and blood draws with cardiac monitoring,
whereas respiratory treatments, steroids, intravenous fluids, and anti-emetics are prime considerations for the pediatric OU. Thus, there may be
greater utilization of an ECG technician or a
phlebotomist in the adult OU, while the respiratory therapist is more needed in the pediatric OU.
Because of the higher frequency of dehydration/
other gastrointestinal complaints, respiratory
diagnoses, and infections encountered in the pediatric OU versus chest pain, syncope, TIA, etc. in
adults, there is a greater need for cardiac monitoring and ECGs in adults, whereas pediatric
patients may have a higher utilization of respiratory treatments, intravenous fluids, steroids,
and antibiotics when compared to adults. This
may have implications for the pharmacy when
stocking medications.
It has also been suggested that the pediatric
OU may exhibit a more marked seasonal and
monthly or daily variation in OU admissions than
adults.
12,19–22
This has been attributed to the pediatric patient population showing greater peaks and
valleys in ED visits, inpatient and OU admissions
depending on whatever acute infectious illness is in
the community. Thus, during rotavirus season,
there may be a sudden marked increase in the
number of infants and children presenting with
dehydration. Similarly, during the winter (in the
Northern Hemisphere) when respiratory illnesses
are prevalent, there are many cases of pneumonia,
croup, and bronchiolitis; during the summer these
illnesses are at their nadir and trauma is more
prevalent in the ED and OU pediatric patient population.
22
Spikes in the number of asthmatics seen in
the ED and, correspondingly, admitted to the OU,
may coincide with the occurrence of pollens, air
pollutants, and/or the prevalence of respiratory illnesses. With adults, the main diagnoses – chest
pain, heart failure, syncope, and TIA – are much
less likely to have seasonal variations.
Patient- and family-centered care should be
the norm. Accommodations should include the
family, for example, parent or guardian, as well
as the patient. Dietary requirements need to be
age appropriate with formula for infants, appropriate tube feedings for those with feeding tubes
and palatable for the child and adolescent as well
as considering those with specialized diets: diabetic, cardiac, lactose intolerant, etc. Toys, games,
and videos help make the OU “patient friendly”
for the child or adolescent. The pediatric OU will
need cribs and appropriate size beds depending
on the ages admitted. This may allow for more
rooms in a fixed space in a pediatric OU than an
adult OU, provided there are provisions for the
parent(s) in the room. (See Chapter 5 on Design.)
Table 53.1 Most Common Diagnoses in an Observation
Unit*
Pediatric** Adult***
1. Asthma
2. Dehydration
3. Gastroenteritis
4. Pneumonia
5. Abdominal pain
6. Seizures
7. Fever
8. Bronchiolitis
9. Croup
10. Poisonings
11. Trauma
1. Chest pain
2. Abdominal pain
3. Asthma: acute
exacerbation
4. Congestive heart
failure (CHF)
5. Chronic obstructive
pulmonary disease: acute
exacerbation
6. Syncope
7. Transient ischemic
attack (TIA)
8. Ureterolithiasis
9. Pyelonephritis
10. Cellulitis/Uncomplicated
Soft Tissue Infections
11. Gastrointestinal bleeding
12. Acute atrial fibrillation
13. Other non TIA, non CVA
neurologic disorders
14. Acute back pain
15. Deep vein thrombosis
16. Trauma
17. Toxicology/overdose
* Represents the common diagnoses seen in our
observation unit from 1994 to 2015.
** Pediatric diagnoses are listed in order of prevalence. Our
prevalence is consistent with other units.
*** In adults, chest pain is undoubtedly the most common
diagnosis in our unit and in other observation units, with
about 80% estimated prevalence.
9
Depending on the
individual observation unit, the prevalence of other
diagnoses varies greatly depending on many factors
including inclusion/exclusion criteria, age of the patient
population seen in the ED; such as high percentage of
elderly, hospital specialty (subspecialty availability and
referral patterns), trauma vs. nontrauma, designated
stroke center, etc. However, generally, abdominal pain
and asthma are the next most common diagnoses,
with syncope, TIA, CHF, COPD exacerbation,
genitourinary complaints (kidney stones, pyelonephritis)
and uncomplicated skin infections in the top ten
adult diagnoses.
Sharon E. Mace
057
21:15:31
Patient Population: Adult versus
Pediatric Patients
As with adults , there are three main categories of
patients: those with a known diagnosis who need
treatment (e.g., heart failure, asthma), those with
a condition or complaint (e.g., chest pain or
abdominal pain) who need a diagnostic evaluation, and those with a known diagn osis who need
monitoring or observation (including atrial fibrillation, syncope, seizure and overdose).
12
As mentioned, the primary diagnoses differ between the
adult and pediatric patients (Table 53.1).
According to the results over 20 years at our
large, urban, academic, non-trau ma, tertiary care
referral center in the United States with a “hybrid”
OU, where hybrid is defined as an OU that
accepts both adult and pediatric patients, the most
common diagnoses for the pediatric patients were
(in order of frequency) asthma, dehydration, gastroenteritis, pneumonia, abdominal pain, seizures,
fever, bronchiolitis, and croup. Results from other
exclusively pediatric OUs in the United States and
internationally have similar results.
22–26
For the
adults, the leading diagnoses (in order of frequency) were chest pain, heart failure, abdominal
pain, syncope, asthma, COPD, dehydration, gastrointestinal bleed, and pneumonia.
12,19–21
Thus,
there is less need for cardiac (rhythm strip) monitoring in the pediatric OU.
Patient Population: Pediatric Patients
in a Pediatric OU
In the United States, the overwhelming majority
of pediatric patients in an OU are “medical,”
which is consistent with our findings,
19–21
with
only 6.0–7.5% of patients in several studies being
a surgical or traumatic condition.
9,27
There is one
exception, a study from a Pediatric Children’s
Hospital in Australia with a mixed patient population that included procedural patients in their
OU. They still found the majority of patients
were medical, although there was a much higher
percentage of surgical patients: medical 56%,
surgical 30%, and the remainder procedural or
psychological.
28
The percentage of pediatric patients placed in
observation status from the ED also varies and
has been reported as 2.9%, 4.0%, and 4.8%,
respectively, in the United States.
22,25,26
The mean
age (years) for pediatric OU patients ranged from
4.36, 4.7, and 6.0 (United States) to 6.23 (Scotland), with one French study having a much lower
median age of 26 months.
22,23,25,27,29
Reported mean LOS (hours) for the pediatric
OU patients ranged from 8.4 to 20.5: Australia
17.5 (community hospital) and 20.5 (tertiary care
hospital); France 14; United States 8.4, 13, 14.7,
15, and 15.6 hours.
9,22–26,30
The LOS (median)
may vary depending on the diagnosis with
respiratory patients tending to have longer LOS
(median): 21.3 (croup) and 16.5 (asthma) versus
poisoning 14.35 or head trauma 13.
9,31–33
The percentage of patients admitted to the hospital from the pediatric OU is quite variable and
ranged from a low of 4% (community hospital,
Australia) to a high of 22% (United States)
28,30
with rates in between these two extremes: 10.4%,
12%, and 20.3%.
24–26
The percentage of OU
patients admitted to the hospital is likely influenced by multiple variables, of which the diagnosis
is one factor. An early study of pediatric OU
patients with gastrointestinal illnesses found
81.5% were discharged home, while discharge rates
for neurologic illnesses (e.g., seizures, head trauma)
were in the 90% range.
34
Amorerecentstudy
found the highest admission rate to inpatient from
the OU was for seizure patients (19%) followed by
asthma (16%) and croup (9%), while the lowest
inpatient admission rates were for enteritis/dehydration at 5% and poisonings at 4%.
25
Another
study had similar findings with respiratory illnesses
having the highest inpatient admission rates from
the OU at 50% for pneumonia, 46% for bronchiolitis, 33% for infections, 23% for asthma, and 17%
for croup. Differing from the other studies, they
found a fairly high admission rate for gastroenteritis at 21%, but only 5% for seizures and 2% for
trauma.
30
A study of pediatric closed head injuries found
only a 5% admission rate to an inpatient unit from
the OU and a study of pediatric poison exposures
found a 5.4% hospitalization rate from the OU.
32,33
In general, for pediatric OU patients, it seems that
poison exposures (nonintentional) and stable blunt
trauma have low hospital admission rates (≤ 5%),
while respiratory conditions (asthma, bronchiolitis,
croup, pneumonia) and infections have the highest
admission rates based on diagnosis.
25,26,30
Reasons for the differences in LOS and admission rates, etc. may include specific diagnosis
or condition, varied setting (academic, tertiary,
teaching vs. nonacademic or community
Pediatric Observation Medicine
057
21:15:31
hospital), country, and the inclusion of procedural patients and/or “holding” admitted patients.
International Perspective
There may be some differences in the types of
pediatric patients placed in a pediatric OU
depending on the international location. A questionnaire sent to facilities in the United Kingdom
noted that 50% of the accident and emergency
departments surveyed had a short-stay ward. Of
these, one-fourth admitted small numbers of children, who are “mainly children who have sustained
trauma-related problems.”
35
This is quite different
from other countries (France, Australia, and United
States), in which medical patients far outnumbered
the surgical patients.
19–21,23,25,26,28,30
In some
regions/countries, trauma patients are admitted to
the hospital and are not considered for placement
in an OU. The United Kingdom study was also a
survey and did not report actual patient data from a
given OU(s) and may be associated with the usual
problems of any survey instrument.
Advantages of Pediatric
Observation Medicine
Cost-Effective
Like adult OM, pediatric OM can have many
benefits. Pediatric OM has been shown to be
cost-effective. Two studies of pediatric asthmatics
and one in croup patients documented this fact.
One report by O’Brien et al. in asthmatics found
the average charge for an inpatient was over five
times greater than for the holding unit.
36
The cost
for asthmatic patients hospitalized as inpatients
for ≤ 1 day was one-and-a-half times greater than
the charges for patients in the holding unit in the
Willett et al. study.
37
For patients with croup,
there was an overall reduction in resource utilization with the medi an charge significantly
decreased (p = 0.03) for OU patients: pre-OU
group was $1,685 versus $1,387 for the post-OU
group.
31
After institution of a short stay unit, an
Australian study estimated a cost savings for
1 year of $1/2 million for one hospital and $2.3
million for another hospital.
28
Quality of Patient Care
A study evaluating the 16-year experience with
croup at an Australian teaching hospital found
that the implementation of the mandatory use of
corticosteroids in 1991 lead to a decrease in the
LOS (from 2.3 days between 1985 and 1990 to
1 day in 1991), number of intubations, and the
number of ICU admissions. Next, in 1993, they
mandated the use of corticosteroids in their OU
and found a marked improvement in their OU
discharge rate from 80% in 1991–1992 to 97% in
1993–1995 or conversely a drop in their admission rate from the OU to the inpatient ward from
20% admitted to only 3% admitted.
38
Comparable
patient care or improved patient care has been
attributed to the pediatric OM. Use of a pediatric
OU for pediatric patients with poison exposures
and for pediatric blunt head trauma patients,
respectively, found no adverse events as a
result of OU placement.
3
Multiple studies of pediatric asthma patients have documented that treatment in the OU is medically effective, safe, and
cost-effective.
3
In the Gururaj et al. study of pedi-
atric asthma tics treated in a holding unit, only
1.5% returned to the ED and none needed
admission.
39
Decreased Hospital Admissions
Studies have documented that the institution of a
pediatric OU does decrease hospital admissions.
There was a significant (p < 0.0001) reduction in
ward admission rates from 9.5% to 4.2% for children/infants with croup after the introduction of
a pediatric OU.
31
A review of pediatric emergency
medicine by Knapp also found that OUs were
valuable in avoiding a hospital admission for
patients with ingestions.
40
A Canadian study in
pediatric asthmatic patients found a significant (p
≤ 0.01) decrease in inpatient admissions from
17% (pre-OU) to 10% (post-OU), but with a significantly (p = 0.01) increased rate of repeat visits
to the ED after discharge (3% pre-OU vs. 5% postOU).
41
This increased rate of return appears to be
an exception to the rule with all other studies
showing no increase or a decrease in return visits
to the ED.
Rate of Returns to the Emergency
Department and Readmissions
Readmissions for hospitalized asthmatic patients
were higher than for holding unit patients. At
1-month follow-up, returns to the ED and
readmissions were: those admitted < 1 day had
Sharon E. Mace
057
21:15:31
31.1% returns to ED with 12.5% readmissions,
those admitted > 1 day had 13.5% returns to ED
with 7.7% readmissions, compared with holding
unit patients who had 11.4% returns to the ED
with no (0%) readmissions.
37
The study by Guoin
et al. looked at the rate of return visits within
72 hours for pediatric asthmatics before and after
the initiation of an OU. Their results were preobservation 12.5% (44/352) returns to the ED
with 39% (17/44) readmitted versus post observation 24.3% (85/350) returned to the ED but fewer
needed readmission, only 28% (24/85).
41
Another
study in asthmatics found no increase in hospital
admission rate after opening an OU.
42
Only 1.5%
of asthmatics treated in a holding unit returned
to the ED and none needed readmission in the
report by Gururaj et al.
39
According to the O’Brien
et al. study, 7% (5/71) of asthmatics returned to the
ED within 1 week of treatment in the holding unit
with 5.6% (4/71) readmitted.
36
Length of Stay
The pediatric OU has a decrease in LOS when
compared to inpatient hospitalization. The median
LOS for pediatric asthmatic patients treated in
an OU is 16.5 hours with a discharge rate
of 67–75%.
9,36,37,41
In one study for pediatric blunt
head trauma patients, the median LOS was
13 hours with a discharge rate of 95%.
33
Astudy
from the United States found a significant decrease
(p = 0.03) from 27.2 to 21.3 hours in median LOS
for patients with croup after the introduction of a
pediatric OU.
31
A study comparing low-risk hyperbilirubinemia patients treated in an OU with inpatient hospitalization demonstrated 82% of patients
were successfully discharged from the OU and OU
patients had a shorter LOS of 18 hours compared
to 42 hours as an inpatient.
44
Patients with intussception (successfully reduced by contrast enema)
when managed in the ED OU had a significantly
shorter LOS than those admitted to the hospital
(mean LOS 7.2 vs. 22.7 hours) with no difference
in outcome.
45
Patient, Parental and Physician
Satisfaction
Another benefit attributed to OM is increased
satisfaction of patients and physicians. The study
by Rydman et al. showed adult patien ts were more
satisfied and had fewer problems with the OU
than they did with routine hospitalization.
43
Rentz
et al. found that the model of a pediatric EDcontrolled OU received high satisfaction ratings
in all areas by community and subspecialty
physicians.
46
Characteristics of Pediatric OU Patients
that Predict Admission
Factors associated with an “inappropriate” OU
admission, defined as a prolonged LOS (> 24
hours) or a short stay < 4 hours were evaluated
in one study. They found that 3% of patients were
discharged home in < 4 hours and 7% of patients
were discharged home in > 24 hours. Variables
identified as significantly associated with an
increased risk of inapprop riate admissions were
age < 1 year, CT or MRI done, IV fluids or
medications, and cardio-respiratory monitoring.
One drawback to this study was the inclusion of
non-OU patients: some patients were in a holding
unit, some in a medical assessment and planning
unit, and others (the majority) were in an OU.
23
In another study, age was not seen as a risk factor
for inpatient admission.
26
In a study of asthmatics, need for supplemental oxygen at the end of
ED management, fever (temperature 38.5°),
and female gender were associated with need for
inpatient admission from the OU.
46
Hybrid Unit
The term “hybrid” unit has several usages.
11,12
If an
OU accepts both adult and pediatric patients in the
same unit, this is a hybrid unit. If the unit accepts
both ED patients for further diagnostic evaluation
and/or treatment and other types of patients, specifically, patients undergoing procedures, particularly at a time when the OU may not be “full” with
ED patients, this has also been termed a “hybrid”
unit. This hybrid unit attempts to make use of the
varied admit/discharge cycle of the typical OU
which tends to be busiest during the evening shift
with ED patients being placed into observation
status, and full at night. Most of the patient discharges are in the morning, so there may be some
temporary bed availability in the afternoon for
non-typical OU patients (post recovery, awaiting
procedures, etc.). There is a possible danger with
this hybrid plan in that on any given day, if the ED
is busy, ED patients may be backed up waiting for
an OU bed, although this has not been reported.
Pediatric Observation Medicine
057
21:15:31
The Future
There is tremendous potential for exponential
growth in pediatric OM throughout the world.
One study from the United States recommends
that 70% of all asthmatics be treated in an OU.
47
An editorial from the United States suggests that
two-thirds to three-fourths of all asthmatics are
potential candidates for an OU instead being
treated as an inpatient.
48
A Canadian health
policy report estimates that 39% of pediatric and
25% of adult patients could be treated in an OU
instead of receiving care as an inpatient.
49
Summary
Like adult OM, pediatric OM needs the same
organizational structure and format. Similarly, no
matter what the patient’sage,OMhasmany
advantages: cost effectiveness, better patient/family
satisfaction, decreased liability, enhanced risk management, psychosocial benefits, decreased LOS,
and most importantly, better patient care and
improved patient outcomes. There are some differences, however, between OM for infants and
children compared to adults: different diagnoses,
and different types of needed resources. Unique
features of pediatric OM include less need for
cardiac monitoring, increased use of respiratory
therapy, greater need for IV fluids, and different
types of pharmacology usage with antibiotics and
antiemetics being the most common medications.
It is very likely that pediatric OM, like adult OM,
will be expanding in the future.
Some units exclude psychiatric patients from a
general OU (as we do) since these patients often
need one on one supervision, more intensive
nursing observation and it may be disruptive to
have a acutely ill psychiatric patient in the bed
next to a low risk chest pain patient. An accidental
overdose in a nonpsychiatric patient may be
acceptable as an appropriate candidate for the
OU. There is also the emergence of separate psychiatric OUs specifically for psychiatric patients,
who are often intoxicated and need to be observed
and reevaluated when they are “sober” and not
under the influence of drugs and/or alcohol. (See
editor’s note on Psychiatric Chapter 60.)
References
1. Emergency Care for Children:
Growing Pains. Committee on
the Future of Emergency Care
in the United States Health
System. (ISBN: 0–30965964–7). ch. 1 Introduction,
p.18. National Academies
Press. www.nap.edu/catalog/
11655.html (Accessed February
2016)
2. www.cdc.gov/nchs/fastats/
emergency-department
.htm (Accessed February
2016)
3. Lamb S, Washington DL, Fink
A, et al. Trends in the Use and
Capacity of California’a
emergency departments
1990–1999. Ann Emerg Med
2002; 39:389–396.
4. Zhou JC, Pan KH, Zhou DY,
et al. High hospital occupancy
is associated with increased risk
for patients boarding in the
emergency department. Amer
J Emerg Med 2012; 125(4):416,
e1–7.
5. Pines JM, Hilton JA, Weber EJ,
et al. International perspectives
on emergency department
crowding. Acad Emerg Med
2011; 18(12); 1358–1370.
6. www.cdc.gov/nchs/data/hus/
2011/093.pdf (Table 93)
(Accessed February 2016)
7. Nawar EW, Niska RW, Xu J;
Division of Health Care Statistics.
Advance Data from Vital and
Health Statistics. National
Hospital Ambulatory Medical
Care Survey: 2005 Emergency
Department Summary, number
386 + June 29, 2007.
8. Hostetler M, Mace SE, Brown
K, et al. Emergency department
overcrowding and children.
Pediatr Emerg Care 2007; 23
(7):507–515.
9. ACEP Observation Medicine
Section. State of the Art:
Observation Units in the
Emergency Department. Policy
Resource and Education Paper.
American College of
Emergency Physicians. Dallas,
TX, 2011. www.acep.org/
search.aspx?searchtext=
observation%20medicine
(Accessed February 2016)
10. Mace SE. Pediatric Observation
Medicine. In: Graff LG, ed.
Observation Medicine: The
Healthcare System’s Tincture of
Time. American College of
Emergency Physicians, Dallas,
TX, 2011, ch. 12.
www.acep.org/Search.aspx?
searchtext=observation%
20medicine%20Observation%
20Medicine%20The%20Health
care%20System%e2%80%99s%
20Tincture%20of%20Time.&
pgsize=10&filter=acep,news,
ecfy,media (Accessed February
2016)
11. Conners GP, Melzer SM,
Committee on Hospital Care
and Committee on Pediatric
Emergency Medicine. Pediatric
Observation Units. Pediatrics
2012:130:172–179.
12. Mace SE. Pediatric Observation
Medicine. Emerg Med Clin
Sharon E. Mace
057
21:15:31
North Amer 2001; 19(1):
239–254.
13. Mace SE. Issues in pediatric
emergency medicine. Foresight
1999; 47:1.
14. Centers for Disease Control:
Nationwide Estimates of
Specific Health Care Needs
Children Qualifiying by
Specific Types of Special
Health Care Needs Criteria.
Atlanta, GA, Centers for
Disease Control, 2006.
15. Goske M, Bulas D, Callahan MJ,
et al. Image gently: progress and
challenges in CT education and
advocacy. Pediatr Radiol 2011;
41(Suppl 2):S461–S466.
16. Klein BL, Patterson M.
Observation unit management
of pediatric emergencies.
Emerg Med Clin North Am
1991; 9:699–676.
17. Graff LG. Observation
Medicine. Boston: Andover
Medical Publishers, Inc; 1993.
18. American College of
Emergency Physicians: Report
on the Preparedness of the
Emergency Department in the
Care of Children. American
College of Emergency
Physicians, Dallas, TX, 1993,
p. 1–.
19. Mace SE. A comparison of
pediatric versus adult
observation medicine patients.
Abstract presented at the Ninth
Annual Midwest Regional
Society for Academic
Emergency Medicine Research
Forum. Ann Arbor, MI,
September 25, 1999.
20. Mace SE. Observing children:
can it be done in a general
hospital? Presented at
Emergency Observation
Conference. Harvard School of
Medicine. ACEP Short Term
Observation Medicine
Conference. Boston, MA,
October 2, 1999.
21. Mace SE. A comparison of
pediatric vs. adult observation
medicine patients. Abstract
presented at the International
Conference of Emergency
Medicine. Boston, MA., May 5,
2000. Ann Emerg Med 35
(suppl): S61, 2000.
22. LeDuc K. An observation
unitin a pediatric emergency
department: one children’s
hospital’s experience. J Emerg
Nursing 2002; 28(5):407–413.
23. Najaf-Zadeh A, Hue V,
Bonnel-Mortuaire C, et al.
Effectiveness of multifunction
paediatric short-stay units: a
French multicentre study. Acta
Paediatrica; e227–e233.
DOI:10.1111/j1651-
2227.2011.02356a.
24. Wiley JF II, Friday JH,
Nowakowski T, et al.
Observation units: the role of
an outpatient extended
treatment site in pediatric care.
Pediatr Emerg Care 2000; 16:
223–229.
25. Scribano PV, Wiley JF 2nd,
Platt K. Use of an observation
unit by a pediatric emergency
department for common
pediatric illnesses. Pediatr
Emerg Care 2001; 17:321–323.
26. Alpern ER, Calello DP,
Windreich R, et al. Utilization
and unexpected hospitalization
rates of a pediatric emergency
department 23- hour
observation unit. Pediatr Emerg
Care 2008; 24(9):589–594.
27. Lamireau T, LLanas B,
Dommange S, et al. A shortstay observation unit improves
care in the paediatric
emergency care setting.
European J Emerg Med 2000; 7:
261–28.
28. Browne GJ. A short stay or
23-hour ward in a general and
academic children’s hospital: are
they effective? Pediatric Emerg
Care 2000; 16(4):223–229.
29. Beattie TF, Moir PA. Paediatric
accident and emergency shortstay ward: a 1-year audit.
Archives Emerg Med 1993; 10
(3):181–186.
30. Crocetti MT, Barone MA, Dritt
Amin D, et al. Pediatric
observation status beds on an
inpatient unit: an integrated
model. Pediatr Emerg Care
2004; 20(1):17–21.
31. Greenberg RA, Dudley NC,
Rittichier KK. A reduction in
hospitalization, length of stay,
and hospital charges for croup
with the institution of a
pediatric observation unit.
Amer J Emerg Med 2006; 24
(7):818–821.
32. Calello DP, Alpern ER,
McDaniel-Yakscoe M, et al.
Observation unit experience
for pediatric poison exposures.
J Medical Toxicology 2009; 5
(1):15–19.
33. Holsti M, Kadish HA, Sill BL,
et al. Pediatric closed head
injuries treated in an
observation unit. Pediatr Emerg
Care 2005; 21(10):639–644.
34. Ellerstein NS, Sullivan TD.
Observation unit in a children’s
hospital. NY State J Med 1980;
80:1684 –
35. Beattie TF, Ferguson J, Moir
PA. Short-stay facilitiess in
accident and emergency
departments for children.
Archives Emerg Med 1993;
10:177–180.
36. O’Brien SR, Hein EN, Sly RM.
Treatment of acute asthmatics
attacks in a holding unit in a
pediatric emergency room.
Ann Allergy 1980; 45:
159–162.
37. Willert C, David AT, Herman
JJ, et al. Short-term holding
room treatment of asthmatics.
J Pediatr 1985; 106:707–711.
38. Geelhoed GC. Sixteen years of
croup in a western Australian
teaching hospital. Effects of
routine steroid treatment. Ann
Emerg Med 1996; 28:621–626.
39. Gururaj VJ, Allen JL, Russo
RM. Short stay in an outpatient
department. Am J Dis Child
1972:123:128–132.
40. Knapp JF. What’ s new in
pediatric emergency medicine.
Pediatr Rev 1997; 18:424–
Pediatric Observation Medicine
057
21:15:31
41. Gouin S, Macarthur C, Parkin
PC, et al. Effect of a pediatric
observation unit on the rate of
hospitalization for asthma.
Ann Emerg Med 1997; 29(2):
218–222.
42. Marks MK, Lovejoy FH Jr.,
Rutherford PA, et al. Impact of
a short stay unit on asthma
patients admitted to a tertiary
pediatric hospital. Quality
Management in Health Care
1997; 6(1):14–22.
43. Rydman RJ, Roberts RR,
Albrecht GL, et al. Patient
satisfaction with an emergency
department asthma
observation unit. Acad Emerg
Med 1999; 6:178–183.
44. Aderonke-Ojo AO, Smitherman
HF, Parker R, et al. Managing
well-appearing neonates with
hyperbilirubinemia in the
emergency department
observation unit. Pediatr Emerg
Care 201: 26(5):343–348.
45. Bajaj L, Roback MG.
Postreduction management of
intussception in a children’s
hospital emergency department.
Pediatrics 2003; 112:1302–1307.
46. Miescier MJ, Nelson DS, Firth
SD, et al. Children with asthma
admitted to a pediatric
observation unit. Pediatr Emerg
Care 2005; 21(10): 645–649.
47. McConnochie AKM, Russo
MJ, McBride JT, et al. How
commonly are children
hospitalized for asthma eligible
for care in alternative settings?
Arch Pediatr Adolesc Med 1999;
153:49–
48. DeAngelis CD. Editor’s Note:
How commonly are children
hospitalized for asthma eligible
for care in alternate settings?
Arch Pediatr Adolesc Med 1999;
153: 49–
49. DeCoster C, Peterson S, Karian
P. Manitoba Centre for Health
Policy and Evaluation: Report
summary alternatives to acute
care. Winnipeg, Manitoba,
Canada. University of ManitobaManitoba Centre for Health
Policy and Evaluation, 1996.
Sharon E. Mace
057
21:15:31
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