Short-stay Observation Research Articles

Bronchiolitis: Can objective criteria predict eligibility for brief hospitalization?

To determine if 3 objective criteria - pulse oximetry, respiratory syncytial virus (RSV) testing, and age - could be used to predict which children hospitalized with bronchiolitis will have brief (<36 hour) hospitalizations and therefore be potential candidates for admission to short-stay observation units. This was a retrospective medical record review of medically uncomplicated children 3 to 24 months of age with emergency department and hospital discharge diagnoses consistent with bronchiolitis who were admitted to a general pediatric ward in our university-based, tertiary care hospital between Jan. 1, 1992, and Nov. 12, 2002. Multiple logistic regression was used to assess the predictor variables. Our study consisted of 225 patients (45% female) with a median age of 7 months (interquartile range [IQR], 4-11 mo; range, 3-22 mo). Median pulse oximetry value was 94% (IQR 91%-96%; range 76%-100%), and 71% of the patients tested positive for RSV. Thirty children (13%) had brief hospitalizations <36 hours, and the median hospital length of stay for the entire study group was 70 hours (IQR 46-108 h; range 6-428 h). None of the 3 predictor variables were independently associated with brief hospitalization. Pulse oximetry, RSV testing and age do not predict which children will have brief hospitalizations and are appropriate candidates for admission to short-stay observation units.

Short-stay units and observation medicine: a systematic review.

To conduct a systematic review of how short-stay observation units (SOUs) affect the efficiency of healthcare delivery and the quality of services provided. MEDLINE, CINAHL, Best Evidence and The Cochrane Library were searched for the period 1 January 1960 to 31 July 2000. Studies were eligible if published in English and rated at National Health and Medical Research Council evidence levels I, II-1, II-2, or II-3; 12 comparative studies published between 1985 and 1998 met these criteria. Data pertaining to clinical outcomes, length of stay, re-presentation rates, emergency department efficiency and costs of care were extracted and evaluated independently. As there was considerable heterogeneity in the patient populations and outcomes, results were summarised rather than subjected to meta-analysis. SOUs have the potential to increase patient satisfaction, reduce length of stay, improve the efficiency of emergency departments and improve cost effectiveness. However, SOUs have commonly been implemented alongside new clinical protocols, and it is not possible to distinguish the relative benefits of each. As demand increases, providing effective and cost-efficient care will become increasingly important. SOUs may help organisations that are attempting to streamline patient care while maintaining their quality of service delivery.

Utilité d’une unité d’hospitalisation de courte durée aux urgences pédiatriques

Short-Stay Observation Units (SSOUs) in paediatric emergency departments are effective in reducing inpatient admissions but can also generate excessive short-stay hospitalisations. The aim of the study was to evaluate both these consequences and the different missions of SSOUs. Methods. – This prospective study included all children admitted in a 10-bed-medico-surgical SSOU of a tertiary-care paediatric emergency department from September 4, to October 31, 2001. At the time of SSOU admission, the physician indicated the purpose of the admission and which decision he would have made in the absence of a SSOU. Results. – Five hundred and nine children (median age = 4 years, chronic disease: 26%, trauma: 34%) were included, accounting for 15% of admissions. The mean length of stay was 14 ± 8h. The decision in the absence of a SSOU would have been: inpatient hospitalization (77%), transfer to another hospital in the absence of inpatient room vacancy (7%), discharge home (10%), prolonged waiting in the emergency ward (4%), do not know or not indicated (2%). The SSOU admission was deemed appropriate in 81%: discharge home within 24h was likely in 65% and the final orientation of the child was uncertain in 16%. The admission was debatable in 13% and inappropriate in 6%. Sixty six per cent of children were discharged home. Conclusion. – The SSOU reduced inpatient hospitalisations, generated few inappropriate short stay hospitalisations, and seemed particularly efficient for paediatric diseases. Proposed indicators should allow inter-hospital comparisons.

A Five-Year Experience of a Short Stay Observation Unit in Saudi Arabia

A Five-Year Experience of a Short Stay Observation Unit in Saudi Arabia

Diagnostic thoracoscopic lung biopsy: an outpatient experience

Background Tissue diagnosis of either interstitial lung disease or indeterminate pulmonary nodules can be obtained by either limited thoracotomy or thoracoscopic lung biopsy. Both procedures traditionally have required hospital admission. We report a series of patients undergoing outpatient thoracoscopic lung biopsy to demonstrate the safety and efficacy of this practice. Methods Sixty-two ambulatory patients with a clinical diagnosis of either interstitial lung disease or indeterminate pulmonary nodule(s) underwent thoracoscopic lung biopsy between June 2000 and June 2001. All procedures were performed with double-lumen endotracheal anesthesia and stapled wedge resection. Chest tubes were removed if no air leak was present and if chest radiograph demonstrated no residual pneumothorax. Results Of 62 patients undergoing thoracoscopic lung biopsy, 45 (72.5%) were discharged home within 8 hours of observation on the day of operation. Fourteen (22.5%) were discharged within 23 hours of their operation. Reasons for 23-hour observation included significant comorbidity (8), pain management (4), postoperative air leak (1), and conversion to muscle-sparing thoracotomy (1). Three (5%) required admission for prolonged air leak (2) or conversion to muscle-sparing thoracotomy (1). Diagnoses were obtained in 61 patients, including neoplasm (25), interstitial lung disease (18), granulomatous disease (7), and other (11). One patient was readmitted for pneumothorax. Patients diagnosed with nonbronchogenic pulmonary metastases were more likely to be discharged on the day of operation. No differences in age, smoking status, or preoperative pulmonary function testing were observed between patients requiring short-stay observation and those discharged immediately after operation. Conclusions Outpatient thoracoscopic lung biopsy is safe and effective, and has become our procedure of choice for diagnosis of either interstitial or focal lung disease.

Epidemiology of poisoning in children: a 7-year survey in a paediatric emergency care unit.

Acute poisoning in children is still a major public health problem, and represents a frequent cause of admission in emergency departments. We carried out an epidemiological study of poisonings leading to admission to a paediatric emergency care unit (PECU). We analysed data from 2988 children who were admitted to the PECU of Bordeaux, France with acute poisoning from 1989 through 1995. During the 7-year period, the poison exposure numbers decreased slightly from 490 to 382 (6% vs. 3% of total medical emergencies). This represented a mean annual incidence of 1.4 poison exposures per 1000 children younger than 18 years of age and living in Bordeaux and its surroundings. Characteristics of the study population, circumstances of poisoning and substances involved were similar to those previously described. Eighty per cent of children were younger than 5 years of age, presented with a benign course. Forty per cent were not treated and 75% were discharged home either immediately or within 24 hours of admission. Only 1.5% of cases, mainly adolescent girls who attempted suicide, were admitted to a paediatric intensive care unit. Overall mortality rate was 0.33/1000. In children, most cases of acute poisoning are accidental, benign, and mainly attributed to the ingestion of a non-toxic substance. This points to the need for better information of the population on availability of poison control centre calling facilities, in order to decrease the number of admissions to the PECU. Patients suspected of having ingested a potentially dangerous substance can be managed in short-stay observation units, thus avoiding unnecessarily prolonged hospitalization. Acute poisoning in children remains a frequent problem, highlighting the need to develop an education programme on primary prevention in our region.

Modalités de réhydratation des diarrhées aiguës du nourrisson à l’hôpital. Impact de la présence permanente d’un pédiatre et d’une structure d’hospitalisation de courte durée

Diarrheal diseases account for 10% of hospitalizations in infants, and large differences in rates of hospitalization have been reported. Objective. – To analyze hospital treatment of infants with acute gastroenteritis, especially the variations in modes of rehydration, hospitalization rates and lengths of stay, related to paediatrician permanency with a short-stay observation unit at their disposal. Methods. – This prospective multicentric study during two rotavirus epidemic periods included 1,187 infants (mean age 10 ± 6 months) with acute gastroenteritis resulting or not in dehydration. During the first period, 12 volunteer hospitals were included. During the second period, we compared six (among the 12) hospitals where infants were admitted in emergency care or pediatric units without pediatric 24-h permanency, with a pediatric emergency care unit having pediatric permanency with a short-stay observation unit. Results. – During the first period, 32% were dehydrated and 6% had hypovolemic shock on admission. The hospitalization rate was 81%. Only 19% of dehydrated infants had exclusively oral rehydration, and 19% of normohydrated infants had intravenous rehydration. During the second period, the hospitalization rate was 42% in the pediatric emergency care unit (28% in the short-stay unit and 14% in hospitalization units) versus 77% in the six hospitals. In the pediatric emergency care unit as compared to the six hospitals, there were a reduction of 65% of hospitalization days, 58% of intravenous accesses, and 66% of laboratory tests. Conclusion. – Our findings suggest that a paediatric permanency with a short-stay observation unit at their disposal improves quality of treatment and is cost-effective.

A short-stay observation unit improves care in the paediatric emergency care setting.

The aim of this study was to evaluate the influence of a short-stay observation unit (SSOU) on the hospitalization rate, the authors have analysed the activity of a SSOU opened in 1992 in a paediatric emergency department (PED) and the number of children hospitalized between 1987 and 1996. Among 2321 patients admitted to the SSOU in 1996, 644 medical patients have been analysed, showing a young population (55% under 3 years old), living in the town or surroundings (70%) and usually have not been referred by a general practitioner (64%). Twenty per cent were admitted for accurate diagnosis (group A), 49% for treatment and observation of a recognized acute pathology before decision of discharge (group B), and 31% waiting for a bed in a paediatric ward (group C). Sixty-eight per cent of children spent less than 6 hours in the SSOU, and 79% of those from groups A and B were thereafter discharged home. Between 1987 and 1991, the number of children hospitalized increased 5% per year on average. After the opening of the SSOU in 1992, this increase has been stopped although the number of medical referrals to PED was still going up. The SSOU in a PED can provide comprehensive care to young children requiring short-term treatment or observation, and is effective in limiting unappropriate hospitalizations.

The short-stay emergency observation ward is here to stay

The traditional venue for the management of most medical and surgical emergencies has been the in-hospital environment. It is only when patients have been fully evaluated and treated that they are discharged. The increasing cost of hospital stay and burgeoning cost of health care are forcing the medical profession to consider options where illnesses can be managed on a more ambulatory basis. The objective of this study was to assess the volume, characteristics, and disposition of emergency department (ED) patients who were managed in the Short-Stay Emergency Observation Ward (SSEOW). A retrospective study of all patients managed in the SSEOW at the Singapore General Hospital (SGH) from July 1 to December 31, 1997 was conducted. The ED case-records of all observed patients were reviewed. Demographic data as well as information on duration of stay, provisional diagnoses, investigations performed, treatment rendered, and disposition were collected. A total of 114,586 patients were seen at the ED during the study period. There were 9,126 (7.9%) patients who were observed and 1,756 (19.2% of observed or 1.5% of total ED attendance) were subsequently admitted. The median duration of observation was 5.6 ± 9.2 hours. The hospitalization rate for male and female patients was almost equal (19.2% versus 19.3%) and those 60 years and older (3,559 or 39.0%) had the highest hospitalization rate (28.0%). The higher the triage priority, the more likely the patient was to be observed and subsequently admitted. Most were observed between 2 to 4 hours (3,288 or 36.0%) and the largest group comprised of those with abdominal complaints (4,115 or 45.1%). Patients with alcohol-related problems were observed the longest (6.7 + 9.8 hours) but had the lowest hospitalization rate (2.6%). The SSEOW allowed a 6.4% savings to direct inpatient admission at SGH. The SSEOW represent a management area for the delivery of short-term and diagnostic care on an ambulatory basis. It is accessible, safe and effective in reducing adions. (Am J Emerg Med 2000;18:629–634.

Safety of Short Stay Observation after Peripheral Vascular Intervention

To determine whether short observation periods (less than or equal to 4 hours) are safe in outpatients undergoing arterial peripheral vascular interventions. A retrospective review of 203 patient medical records from the Interventional Vascular Department for 239 lower extremity or abdominal procedures (161 men and 78 women) during a 5-year period was completed. The average patient age was 62.2 years (range, 32-83 years). Thirty-six patients had more than one procedure. Indication, intervention, coagulation status, complication rate, and hospitalizations within 7 days after discharge from the short stay unit (SSU) were reviewed and the outcome was measured. Patients were grouped according to the length of their observation period (< or =4 hours or >4 hours) for statistical analysis. In 85% of the procedures (204 procedures), claudication was the primary indication for intervention. Angioplasty (203 procedures) was also commonly performed. Ninety procedures (38%) required stent placement, and other interventional procedures performed were pulse-spray thrombolysis (eight procedures), atherectomy (two procedures), and stent-graft placement (one procedure). None of the patients required hospitalization as a result of their radiologic intervention within 7 days after discharge from the SSU. Specifically, there were no major "at home" complications in patients discharged after an observation period of < or =4 hours. Two patients were admitted for outpatient procedures and were subsequently hospitalized as a result of a complication from the procedure. The complication rate (including minor complications) was 8% (seven of 87) in the < or =4 hour observation period group compared with 24.3% (37 of 152) in the >4 hour group (P < .01). This difference was due to a greater number of minor hematomas in the >4 hour group. Based on the authors' findings, many interventional vascular procedures can be performed safely on an outpatient basis with relatively short observation times. Early discharge from the SSU did not result in an increased readmission rate to the hospital because of delayed complications.

Cost-effectiveness of a new short-stay unit to “rule out” acute myocardial infarction in low risk patients

Objectives. This study attempted to determine the safety and costs of a new short-stay unit for low risk patients who may be admitted to a hospital to rule out myocardial infarction or ischemia.Background. One strategy to reduce the costs of ruling out acute myocardial infarction in low risk patients is to develop alternatives to coronary care units.Methods. The short-term and 6-month clinical outcomes and costs for 592 patients admitted to a short-stay coronary observation unit at Brigham and Women's Hospital with a low (≤ 10%) probability of acute myocardial infarction were compared with those for 924 consecutive comparison patients who were eligible for the same unit but were admitted to other hospital settings or discharged home. Actual costs were calculated using detailed cost-accounting methods that incorporated nursing intensity weights.Results. The rate of major complications, recurrent myocardial infarction or cardiac death during 6 months after the initial presentation of the 592 patients admitted to the coronary observation unit was similar to that of the 924 comparison patients before and after adjustment for clinical factors influencing triage and initial diagnoses (adjusted relative risk 0.86, 95% confidence interval 0.49 to 1.53). Their median total costs (25th, 75th percentile) at 6 months ($1,927; 1,455, 3,650) were significantly lower than for comparison patients admitted to the wards ($4,712; 1,868, 11,187), to stepdown or intermediate care units ($4,031; 2,069, 9,169) or to the coronary care unit ($9,201; 3,171, 20,011) but were higher than for comparison patients discharged home from the emergency department ($403; 403, 927) before and after the same adjustments (all adjusted p < 0.0001).Conclusions. These data suggest that the coronary observation unit may be a safe and cost-saving alternative to current triage strategies for patients with a low risk of acute myocardial infarction admitted from the emergency department. Its replication in other hospitals should be tested.

Outcome of patients who were admitted to a new short-stay unit to “rule-out” myocardial infarction

For emergency room patients with a low probability of acute myocardial infarction, we established a new short-stay coronary observation unit, a 2-bed nonintensive care unit with telemetry monitoring adjacent to the emergency room. Of 512 consecutive admissions to the coronary observation unit, 425 (83%) were discharged home without evidence of acute myocardial infarction or serious complications (mean length of stay, 1.2 days; median length of stay, 1 day); 87 (17%) were transferred to other hospital beds. The rate of acute myocardial infarction was 3%. No deaths and only 1 serious complication occurred in the coronary observation unit. At 6 month follow-up, the cardiac survival rate was 99% for patients sent home directly from this unit. It is concluded that the coronary observation unit is safe and adequate for ruling out acute myocardial infarction in a defined subset of patients. Short-stay units, however, encourage early discharges which, when premature, may miss patients who are at risk of having complications shortly thereafter. Strategies such as mandatory but expeditious predischarge stress testing to encourage early but not premature discharge may augment the efficiency of coronary observation units.

Combined short-stay/day surgery/investigation unit in a district general hospital.

Over the past few years there has been a growing interest in seeking alternatives to traditionally accepted patterns of in patient care. The reasons for this development are probably complex but are partly attributable to the economics of providing health care. Examples of facilities evolved as a result of this trend are units for day surgery, programmed investigation, five-day wards, and short-stay wards. There are many references to the operation of short-stay observation wards attached to accident and emergency depart? ments,1-4 five-day wards,5 programmed investigation,6 7 and day surgery units.8 9 These references mostly described units developed as discrete entities performing one function only. We describe a unit that from its inception was intended to fulfil three functions?namely, a short-stay observation ward for a major accident and emergency department and an in? vestigation and day surgery unit for both medical and surgical specialties. It is our contention, on the basis of the results for six months, that (a) such a unit can function efficiently and (b) it contributes to making the maximum use of expensive capital resources.

An evaluation of the functions of the short-stay observation ward in the accident and emergency department.

Obstructive sleep apnoea (OSA) and restless legs syndrome (RLS) are two of the most prevalent sleep disorders and can coexist within the same patient. Nonetheless, the recognition of RLS among OSA patients has important clinical implications, since RLS can disrupt sleep despite adequate treatment of sleep disordered breathing and should be treated accordingly. Furthermore, the presence of OSA can also increase the severity of RLS. Therefore, it is important to be able to correctly identify both disorders and treat them effectively. The present article reviews our current knowledge on this comorbidity and discusses potential treatment options for RLS in the context of OSA.