In the 40 years since the first studies of pediatric OUs, several US health systems have extended observation services to children. This model of care may be expanding, as suggested by an increase in the number of publications in the past ten years. However, the number of centers within the US reporting on their OU experience remains small. Our systematic review identified a recurrent theme related to OUs - the opportunity to improve operational processes of care compared with the traditional inpatient alternative. We have identified the need to standardize OU outcomes and propose measures for future OU research.
Observation Unit Operations
The OU care model expands outpatient management of acute conditions to include children who are neither ready for discharge nor clear candidates for inpatient admission. OUs have demonstrated the ability to care for patients across the pediatric age spectrum. Over the decades spanning these publications, advances in medical therapy such as anti-emetics for gastroenteritis and early administration of systemic steroids for asthma may have resulted in lower admission rates or shorter time to recovery (44
). Despite these advances, there are marked consistencies in the conditions cared for within OUs over time. The data summarized here may help guide institutions as they consider specific pediatric conditions amenable to observation care.
The hospitals included in this review either added physical space or revised services within existing structures to establish their OU. Hospitals facing physical constraints may look to underutilized areas, such as recovery rooms, to provide observation care, as observation does not require the use of licensed inpatient beds. Several units have responded to daily fluctuations in unscheduled observation cases by also serving patients who require outpatient procedures, brief therapeutic interventions, and diagnostic testing. By caring for patients with these scheduled care needs during the day, there is a more steady flow of patients into the OU. While hospitals traditionally have used post-anesthesia care units and treatment rooms for scheduled cases, OUs appear to benefit from the consistent resource allocation associated with a constant demand for services.
To date, the vast majority of pediatric OUs in the published literature have emerged as an extension of ED services. Now, with the expansion of pediatric hospitalist services and movement toward 24/7 inpatient physician coverage, there may be increased development of ward-based OUs and the designation of inpatient observation status. While ward-based OUs managed by pediatric hospitalists may be well established, we were not able to identify published reports on this structure of care. A national survey of health systems should be undertaken to gather information regarding the current state of pediatric observation services.
When creating policies and procedures for OUs, input should be sought from stakeholders including hospitalists, PEM providers, primary care providers, sub-specialists, mid-level providers, nurses, and ancillary staff. As patients requiring observation level of care do not neatly fit an outpatient or inpatient designation, they present an opportunity for hospitalist and PEM physician groups to collaborate (46
). Calling on the clinical experiences of inpatient and ED providers could offer unique perspectives leading to the development of innovative observation care models.
This review focused on institutions with dedicated observation services, which in all but one study (26
) consisted of a defined geographic unit. It is possible that the practices implemented in an OU could have hospital-wide impact. For example, one study reported reduction in LOS for all asthma cases after opening a ward-based unit (7
). Further, pediatric hospitalist services have been associated with shorter LOS (49
) and increased use of observation status beds compared with traditional ward services (50
). As pediatric hospitalists expand their scope of practice to include both observation and inpatient care, clinical practice may be enhanced across these care areas. It follows that the impact of observation protocols on care in the ward setting should be independently evaluated.
The costs associated with the establishment and daily operations of an OU were not addressed in the reviewed publications. Assertions that observation provides a cost-effective alternative to inpatient care (4
) should be balanced by the possibility that OUs extend care for patients who could otherwise be discharged directly home. Studies have not evaluated the cost of OU care compared with ED care alone. Research is also needed to assess variations in testing and treatment intensity in OUs compared with the ED and inpatient alternatives. Reimbursement for observation is dependent in part upon institutional contracts with payers. A full discussion of reimbursement issues around observation services is beyond the scope of this review.
Observation Unit Outcomes
Length of stay
Although most studies reported LOS, direct comparisons across institutions are difficult given the lack of a consistently referenced start to the observation period. Without this, LOS could begin at the time of ED arrival, time of first treatment, or time of admission to the OU. Identifying and reporting the elements contributing to LOS for observation care is necessary. The time of OU admission is important for billing considerations; the time of first treatment is important to understanding the patient's response to medical interventions; the time of ED arrival is important to evaluating ED efficiency. Each of these LOS measures should be reported in future studies.
Direct comparisons of LOS are further complicated by variability in the maximum permissible duration of an OU stay, ranging from 8 to 24 hours in the included studies. Despite these limits, some OU care will extend beyond set limits due to structural bottlenecks. For example, once the inpatient setting reaches capacity, observation LOS for patients who require admission will be prolonged. The best evaluation of LOS would come from prospective study design utilizing either randomization or quality improvement methods.
Defining Success and Failure in Observation Care
In the reviewed literature, “observation failures” have been defined in terms of admission after observation and unscheduled return visit rates. Admission rates are heavily dependent on appropriate selection of cases for observation. Although some observation cases are expected to require inpatient admission, OUs should question the validity of their unit's acceptance guidelines if the rate of admission is >30% (51
). High rates could be the result of inadequate treatment or the selection of children too sick to improve within 24 hours. Low rates could indicate over-utilization of observation for children who could be discharged directly home. Full reporting on the number of children presenting with a given condition and the different disposition pathways for each is needed to evaluate the success of OUs. Condition-specific benchmarks for admission after observation rates could guide hospitals in their continuous improvement processes.
Unscheduled return visits may reflect premature discharge from care, diagnostic errors, or development of a new illness. OU care may influence patient adherence to scheduled follow-up care but this has not been evaluated to date. In future research, both scheduled and unscheduled return visits following ED visits, observation stays, and brief inpatient admissions for similar disease states should be reported for comparison. Standard methodology for identifying return visits should include medical record review, claims analyses, and direct patient contact.
As hospitals function at or near capacity (52
), it becomes important to delineate the appropriate length of time to monitor for response to treatments in a given setting. Limited capacity was a frequently cited reason for opening a pediatric OU; however the impact of OUs on capacity has not yet been evaluated. Operations research methods could be used to model OU services' potential to expand hospital capacity. This research could be guided by evaluation of administrative data from across institutions to identify current best practices for pediatric OU and observation status care.
OU benchmarking in the US has begun with a small number of adult units participating in the ED OU Benchmark Alliance (EDOBA) (54
). In we propose dashboard measures for pediatric OU continuous quality improvement. The proposed measures emphasize the role of observation along the continuum of care for acute conditions, from the ED through the OU with or without an inpatient stay to clinic follow-up. Depending on the structure of observation services, individual institutions may select to monitor different dashboard measures from the proposed list. Patient safety and quality of care measures for the conditions commonly receiving pediatric OU care should also be developed.
Suggested Dashboard Measures for Pediatric Observation Units
The most important limitations to this review are the heterogeneity in interventions and reporting of outcomes, which precluded our ability to combine data or conduct meta-analyses. We attempted to organize the outcomes data into clear and consistent groupings. However, we could not compare the performance of one center with another due to differences in OU structure, function and design.
In order to focus this systematic review, we chose to include only peer reviewed publications that describe pediatric OUs within the US. This excludes expert guidelines, which may be of value to institutions developing observation services.
Our search found only a small number of centers that utilize OUs and have published their experience. Thus our review is likely subject to publication bias. Along this line, we identified 9 additional publications where children were cared for alongside adults within a general OU (55
). This suggests an unmeasured group of children under observation in general EDs, where more than 90% of US children receive acute care (64
). These articles were excluded because we were unable to distinguish pediatric specific outcomes from the larger study population.
Finally, retrospective study design is subject to information bias. Without a comparable control group, it is difficult to understand the effects of OUs. Patients directly admitted or discharged from the ED and patients who require admission after observation all differ from patients discharged from observation in ways that should be controlled for with a randomized study design.