Improving Outcomes by Skipping the ED

Improving Outcomes by Skipping the ED

A study examines how some pediatric patients can benefit from direct admission to inpatient care.
Doctor examining young patient.

An ongoing study could have a significant impact on emergency department utilization at children’s hospitals. Three years into the study assessing the efficacy of direct admissions to an inpatient floor, researchers have observed no adverse effects or unplanned ICU transfers among their directly admitted patients.

The study — funded by Patient-Centered Outcomes Research Institute (PCORI) and conducted at Dartmouth-Hitchcock Medical Center, Nationwide Children’s, UPMC Children’s Hospital of Pittsburgh, and nearly 50 clinics across the nation — compares how quickly children receive care through direct admissions when compared to admission through an ED and whether the process improves families' experiences.

“We hypothesized that direct admission for certain conditions would be advantageous for the patient, their family, and the system,” says Allison Fleischer, MD, pediatric hospitalist, member of the Paul C. Gaffney Division of Pediatric Hospital Medicine at UPMC Children’s Hospital of Pittsburgh and co-investigator for the PCORI study. “But that's actually not been studied widely in children.”

The potential benefits are numerous, including:

  • Direct admissions improve ED throughput and eases overcrowding concerns.
  • Immunocompromised children who are stable but require hospitalization avoid the risk of acquiring infections from the ED environment.
  • Families avoid charges associated with an ED visit.
  • Bypassing the ED expedites patients to the appropriate level of care.

Criteria and evaluation

The study began in 2019 and is scheduled to run through November 2024. It will include nearly 2,000 pediatric cases and will measure the timeliness of care provided to patients who bypass the ED compared to traditionally admitted patients, among other metrics. The research is being led by Joanna Leyenaar, MD, pediatric hospitalist at Dartmouth-Hitchcock Medical Center.

Fleischer says so far there have been no adverse effects or unplanned ICU transfers among their direct admission patients. And the feedback from participating patient families has been overwhelmingly positive.

During a medical visit with a pediatrician, families are provided with the option to participate in the study if their child needs to be admitted to the hospital for medical care. The referring doctor communicates directly with the care team at the hospital to ensure they can accommodate an inpatient admission and relay pertinent information about the patient’s condition. Patient families wishing to bypass the ED in favor of a direct admission must also meet eligibility requirements:

  • The researchers are generally excluding patients under 60 days of age due to the potential of a fever, which could require ED evaluation and testing.
  • The patient must currently be at their pediatrician’s office and in stable condition, not requiring emergency care.
  • Typically, an ideal candidate for direct admission has already unsuccessfully tried outpatient therapy, such as antibiotics for pneumonia or a urinary tract infection.
  • Diagnoses that fit the study criteria include skin and soft tissue infections without abscesses, dehydration, fever, and other nonspecific viral illnesses. With each diagnosis there are specific details which may preclude direct admission. Diagnoses such as hypoxemia and severe electrolyte derangements are not appropriate for direct admission.

To ensure the child receives timely care, it’s important that patient families understand that they’re going straight to an inpatient bed. “They're likely going to spend the night, if not a little bit longer, and they need to go directly to the children's hospital,” Fleischer says. “So, it's not a stop at McDonald's or stopping at home to pack a bag—they go directly from the pediatrician's office.”

Communication is crucial

Strong communication is essential for success. Not only is the care team aligned, from the referring physician to the patient flow coordinator and hospital care team, but the researchers have been deliberate to involve and inform parents every step of the way. Patient families are part of the advisory board and were engaged in the early stages of planning for the study. And the researchers produced brochures for the pediatricians’ offices to ensure parents know exactly where to go and what to do when arriving at the hospital for their direct admission.

“It helps smooth that process for the family because setting up their expectations is so important for their overall experience,” says Sylvia Choi, MD, FAAP, pediatric hospitalist, member of the Paul C. Gaffney Division of Pediatric Hospital Medicine at UPMC Children’s Hospital of Pittsburgh and co-investigator and clinical co-lead for the PCORI study. “Families who have participated in the study have found direct admission easier for them overall and have thought the care they received was excellent. We've had highly positive feedback.”

This article adapted content from the podcast That’s Pediatrics by UPMC Children’s Hospital of Pittsburgh.

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