Effect of using pediatric emergency department virtual observation on inpatient admissions and lengths of stay.

OBJECTIVE: To determine whether using emergency department (ED) virtual observation for select pediatric conditions decreases admission rates for these conditions, and to examine effects on length of stay. METHODS: The option of ED virtual observation care for 9 common pediatric conditions was introduced in 2009; associated order sets were developed. Retrospective secondary analyses of administrative data from our tertiary care pediatric ED and children's hospital were performed for the year before (year 0) and after (year 1) this disposition option was introduced. The proportion of visits admitted to the inpatient unit and length of stay (LOS) were determined for all visits considered eligible for ED virtual observation care on the basis of diagnosis codes for both study years. RESULTS: There were 1614 observation-eligible visits in year 0 and 1510 in year 1. In year 1, 18% (n = 266) of observation-eligible visits received ED virtual observation care. Admission rates for observation-eligible visits were similar after this model of care was introduced (25% year 0, 29% year 1, P = .02). Median LOS for ED virtual observation visits was 8.8 hours (interquartile range 6.5-12.4). ED LOS was shorter for ED discharges (5.6 hours year 0, 5.1 hours year 1, P < .001) and unchanged for admissions (6.0 hours year 0, 5.8 hours, year 1, P = .41) after introducing ED virtual observation. CONCLUSIONS: Admission rates for observation-eligible visits were not lower in the year after ED virtual observation care was introduced. LOS decreased for ED discharges and was unchanged for admissions. Reevaluation of the effects of pediatric ED virtual observation on admission rates and LOS after longer periods of use is indicated.

Underlying Rationale and Approach to Treat Hypertension in Adolescents by Physicians of Different Specialty.

OBJECTIVE: To describe the underlying clinical decision-making rationale among general pediatricians, family physicians, pediatric cardiologists and pediatric nephrologists in their approach to an adolescent with hypertension. METHODS: We conducted semi-structured phone interviews with a convenience sample of physicians from the above-mentioned 4 specialties. Each participant was asked to "think aloud" regarding their approach to a hypothetical patient - 12 year old boy with persistent hypertension for 6 months. Standardized open-ended questions about potential factors that could affect physicians' diagnosis and treatment strategies (e.g., patient age) were used. Interviews were audio-recorded; transcribed verbatim; transcripts were independently coded by 2 investigators; emergent themes identified and inter-coder agreement achieved. Thematic analysis was performed based on grounded theory. RESULTS: Nineteen participants included 5 general pediatricians, 5 pediatric cardiologists, 5 pediatric nephrologists and 4 family physicians. Five themes emerged: 1) Accuracy of blood pressure measurement and hypertension diagnosis, 2) Shift in the epidemiology of pediatric hypertension from secondary to primary hypertension, 3) Patient characteristics considered in the decision to initiate workup, 4) Obesity-centered choice of diagnostic tests and lifestyle modifications, and 5) Variable threshold for initiating antihypertensive pharmacotherapy vs. referral to hypertension specialists. CONCLUSIONS: There is variation across primary care and specialty physicians who provide care for children and adolescents with hypertension. Key areas of variability include the willingness to initiate antihypertensive medications, the use of diagnostic tests (e.g., ambulatory blood pressure monitoring), and the perceived need for specialty referral. Further study is needed to assess whether different treatment paradigms result in differential patient outcomes.