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Structure and Function of Observation Units in Children's Hospitals: A Mixed-Methods Study
Leticia A Shanley1, Carla Hronek2, Matthew Hall2
1Department of Pediatrics, Children's Medical Center of Dallas, University of Texas Southwestern Medical Center, Dallas, Tex.
Insights
Pediatric observation units (OUs) are common in high-volume children's hospitals but lack standardized practices. These units often function as hybrid models with rapid turnover, posing challenges for consistent patient care and outcomes.
Area of Science:
- Pediatric Healthcare Operations
- Hospital Management
- Quality Improvement in Medicine
Background:
- Observation units (OUs) are increasingly used to manage healthcare resources and costs.
- The operational characteristics of pediatric OUs are not well understood.
- This study addresses the gap in knowledge regarding pediatric OU infrastructure and function.
Purpose of the Study:
- To characterize the infrastructure and operational function of pediatric observation units in freestanding children's hospitals.
- To compare the characteristics of hospitals with and without pediatric OUs.
- To identify operational challenges and best practices in pediatric OU management.
Main Methods:
- A survey of 43 freestanding children's hospitals within the Pediatric Health Information System was conducted in 2013.
- Hospitals with OUs admitting unscheduled patients from the emergency department (ED) in 2011 were identified.
- Semistructured interviews were performed with representatives from hospitals with OUs, and data were compared between hospitals with and without OUs.
Main Results:
- 14 of 43 (33%) hospitals had an OU in 2011. Hospitals with OUs had more beds and higher annual ED visits.
- Most OUs were located in the ED, had fewer than 12 beds, and operated as hybrid units (65%) offering scheduled services.
- Admissions were often intuition-based, patient suitability varied, rapid turnover was a focus, and outcome measures were inconsistent. Challenges included copayments and utilization reviews.
Conclusions:
- Pediatric OUs are prevalent in higher-volume hospitals but exhibit significant variation in location, size, and staffing.
- Most OUs function as hybrid units, admitting patients based on intuition with a culture of rapid patient turnover.
- Inconsistent outcome measures and challenges with utilization review and patient copayments highlight areas for improvement in pediatric OU operations.
Objective:
Observation unit (OU) use has been promoted recently to decrease resource utilization and costs for select patients, but little is known about the operations of pediatric OUs. This study aimed to characterize the infrastructure and function of OUs within freestanding children's hospitals and to compare characteristics between hospitals with and without OUs.
Methods:
All 43 freestanding children's hospitals that submit data to the Pediatric Health Information System were contacted in 2013 to identify OUs that admitted unscheduled patients from their emergency department (ED) in 2011. Semistructured interviews were conducted with representatives at hospitals with these OUs. Characteristics of hospitals with and without OUs were compared.
Results:
Fourteen (33%) of 43 hospitals had an OU during 2011. Hospitals with OUs had more beds and more annual ED visits compared to those without OUs. Most OUs (65%) were located in the ED and had <12 beds (65%). Staffing models and patient populations differed between OUs. Nearly 60% were hybrid OUs, providing scheduled services. OUs lacked uniform outcome measures. Themes included: admissions were intuition based, certain patients were not well suited for OUs, OUs had rapid-turnover cultures, and the designation of observation status was arbitrary. Challenges included patient discontent with copayments and payer-driven utilization reviews.
Conclusions:
OUs were located in higher volume hospitals and varied by location, size, and staffing. Most functioned as hybrid OUs. OUs based admissions on intuition, had staffing cultures centered on rapid turnover of patient care, lacked consistent outcome measures, and faced challenges regarding utilization review and patient copayments.
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