Pediatric Observation Units

Conners, Gregory P.; Melzer, Sanford M.; Percelay, Jack M.; Betts, James M.; Chitkara, Maribeth; Jewell, Jennifer A.; Lye, Patricia S.; Mirkinson, Laura J.; Eichner, Jerrold M.; Brown, Chris; Lostocco, Lynne; Salerno, Richard; Heiss, Kurt F.; Scanlon, Matthew C.; Alexander, S. Niccole; Shaw, Kathy N.; Ackerman, Alice D.; Chun, Thomas H.; Dudley, Nanette C.; Fein, Joel A.; Fuchs, Susan; Moore, Brian R.; Selbst, Steven M.; Wright, Joseph L.; Barata, Isabel A.; Bullock, Kim; Gross, Toni; Edgerton, Elizabeth A.; Haro, Tamar Magarik; Haymon, Jaclynn S.; Johnson, Cynthia Wright; Romig, Lou E.; Snow, Sally K.; Tuggle, David W.; Tellez, Sue

doi:10.1542/peds.2012-1358

Cited by 24 publications

(15 citation statements)

References 39 publications

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“…Providers caring for observation-status patients often are not even aware of their patients' designation and do not differentiate them from their inpatient-status patients. 22,23 Observation status is determined by payers, typically using criteria provided by InterQual 24 and Milliman, 25 which differ from each other and add to the inconsistency. Although the present study cannot determine how or why certain patients were assigned to observation status, the fact that patients receiving antivenom are consuming high-resource, high-cost treatments raises questions about the appropriateness of this billing designation for these patients.…”

Section: Discussionmentioning

confidence: 99%

“…Patients in an observation unit may not be designated as observation status for billing purposes. 23 Although observation unit care may be an effective setting to care for some pediatric patients exposed to poisons of a nonvenomous nature, 29 observation status does not seem to be an appropriate billing designation for patients being treated with antivenom. Although these patients may spend only a short time in the hospital, the receipt of antivenom includes high levels of resource utilization, particularly in terms of the purchase price of the treatment and the need for subsequent monitoring of response to therapy; it is not a state of decision-making.…”

Section: Discussionmentioning

confidence: 99%

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Resource Utilization of Pediatric Patients Exposed to Venom

Narra

Lie

Hall

et al. 2014

Hospital Pediatrics

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BACKGROUND AND OBJECTIVE:Treating envenomation with antivenom is costly. Many patients being treated with antivenom are in observation status, a billing designation for patients considered to need care that is less resourceintensive, and less expensive, than inpatient care. Observation status is also associated with lower hospital reimbursements and higher patient cost-sharing. The goal of this study was to examine resource utilization for treatment of envenomation under observation and inpatient status, and to compare patients in observation status receiving antivenom with all other patients in observation status. METHODS:This was a retrospective study of patients with a primary diagnosis of toxic effect of venom seen during 2009 at 33 freestanding children's hospitals in the Pediatric Health Information System. Data on age, length of stay, adjusted costs (ratio cost to charges), ICU fl ags, and antivenom utilization were collected. Comparisons were conducted according to admission status (emergency department only, observation status, and inpatient status), and between patients in observation status receiving antivenom and patients in observation status with other diagnoses. RESULTS:A total of 2755 patients had a primary diagnosis of toxic effect of venom. Of the 335 hospitalized, either under observation (n = 124) or inpatient (n = 211) status, 107 (31.9%) received antivenom. Of those hospitalized patients receiving antivenom, 24 (22.4%) were designated as observation status. Costs were substantially higher for patients who received antivenom and were driven by pharmacy costs (mean cost: $17 665 for observation status, $20 503 for inpatient status). Mean costs for the 47 162 patients in observation status with other diagnoses were $3001 compared with $17 665 for observation-status patients who received antivenom. 6-8 However, few studies have addressed the treatment burden associated with envenomation cases or the impact of the designated medical service type on resource utilization and costs. CONCLUSIONS:The Centers for Medicare & Medicaid Services (CMS) coined the term "observation status" to describe patients not meeting inpatient Diagnosis Related Group criteria and deemed by payers to be in a state of clinical decisionmaking between discharge-to-home and admission-to-inpatient status. 9They defined the care a patient receives while in observation status as a set of services delivered "before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital."10 Because patients in observation status have not officially been admitted to the hospital, the care they receive in emergency departments (EDs) or in the hospital is considered outpatient care and is commonly reimbursed at lower rates than care provided to patients with an inpatient status, as observation-status care is presumed to be less resourceintensive.11 Antivenom treatments followed by ongoing care (including being observed for complications)...

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Resource Utilization of Pediatric Patients Exposed to Venom

Narra

Lie

Hall

et al. 2014

Hospital Pediatrics

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“…The types of patients best served in these units include those with asthma, croup, gastroenteritis, dehydration, abdominal pain, and poisoning. [104][105][106][107][108] If the ED space and staffing are insufficient to adequately justify either an urgent care or observation service, another model can be used. A hybrid unit can be successfully created by sharing or combining resources with general pediatric inpatient or other pediatric outpatient services.…”

Section: Ed To Observation Units or Inpatient Transitionmentioning

confidence: 99%

Best Practices for Improving Flow and Care of Pediatric Patients in the Emergency Department

Barata¹,

Brown²,

Fitzmaurice³

et al. 2015

Pediatrics

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This report provides a summary of best practices for improving flow, reducing waiting times, and improving the quality of care of pediatric patients in the emergency department. CURRENT STATUS AND NEEDS ED Use and ED Crowding in the United StatesApproximately 800 000 children seek care in the emergency department (ED) each day in the United States. Additionally, it is estimated that 3.4% of US children use EDs as their source for sick care. The vast majority (92%) of these children are seen in community EDs, with a smaller percentage seen in pediatric EDs. The increase in ED utilization has saturated the capacity of EDs and emergency medical services in many communities. Increases in patient volume and decreases in resources, including fragmentation of resources and shortage of critical subspecialists, have resulted in EDs facing crowding and ambulance diversion.The need for emergency medical services outstrips the available resources on a daily basis. This mismatch is reflected by the considerable increase in the number of patients visiting EDs. In 1993, 90.3 million patients visited EDs; in 2003 that number increased to 113.9 million patients. Approximately 21% of these patients were younger than 15 years. Despite the increase in ED visits, the number of hospitals decreased by 703, the number of hospital beds decreased by 198 000, and the number of EDs decreased by 425.

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“…But, providers caring for observationstatus patients may not differentiate them from inpatient-status patients. 6,7 The care team may not know the billing status during hospitalization. Inconsistent application of billing status may lead to patients of the same complexity and LOS, with the same resource utilization, being coded as observation status in 1 hospital and inpatient status in another hospital or even within the same hospital.…”

Section: (Continued On Last Page)mentioning

confidence: 99%

“…7,18,19 However, designated observation units for children are not common, even in children' s hospitals. 6,20,21 Therefore, we suspect that most patients in our analysis were cared for in a regular inpatient unit.…”

Section: Figurementioning

confidence: 99%

Resource Utilization for Observation-Status Stays at Children’s Hospitals

et al. 2013

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BACKGROUND AND OBJECTIVE: Observation status, in contrast to inpatient status, is a billing designation for hospital payment. Observation-status stays are presumed to be shorter and less resource-intensive, but utilization for pediatric observation-status stays has not been studied. The goal of this study was to describe resource utilization characteristics for patients in observation and inpatient status in a national cohort of hospitalized children in the Pediatric Health Information System. METHODS: This study was a retrospective cohort from 2010 of observation- and inpatient-status stays of ≤2 days; all children were admitted from the emergency department. Costs were analyzed and described. Comparison between costs adjusting for age, severity, and length of stay were conducted by using random-effect mixed models to account for clustering of patients within hospitals. RESULTS: Observation status was assigned to 67 230 (33.3%) discharges, but its use varied across hospitals (2%–45%). Observation-status stays had total median costs of $2559, including room costs and $678 excluding room costs. Twenty-five diagnoses accounted for 74% of stays in observation status, 4 of which were used for detailed analyses: asthma (n = 6352), viral gastroenteritis (n = 4043), bronchiolitis (n = 3537), and seizure (n = 3289). On average, after risk adjustment, observation-status stays cost $260 less than inpatient-status stays for these select 4 diagnoses. Large overlaps in costs were demonstrated for both types of stay. CONCLUSIONS: Variability in use of observation status with large overlap in costs and potential lower reimbursement compared with inpatient status calls into question the utility of segmenting patients according to billing status and highlights a financial risk for institutions with a high volume of pediatric patients in observation status.

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Pediatric Observation Units

Cited by 24 publications

References 39 publications

Resource Utilization of Pediatric Patients Exposed to Venom

Resource Utilization of Pediatric Patients Exposed to Venom

Best Practices for Improving Flow and Care of Pediatric Patients in the Emergency Department

Resource Utilization for Observation-Status Stays at Children’s Hospitals

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