Comparative Effectiveness of Direct Admission & Admission Through Emergency Departments for Children

Not Applicable

Completed

Brief Summary: At a national level, emergency departments (EDs) serve as the portal of hospital admission for 75% of hospitalized children. The remainder occur via direct admission, defined as admission to hospital without first receiving care in the hospital's ED. The overall goals of this research are to: (i) implement pediatric direct admission systems at 3 hospitals, (ii) compare the timeliness of healthcare delivery for children who are admitted directly and through emergency departments, (iii) determine which patient populations achieve the greatest benefits from direct admission, and (iv) identify barriers and facilitators of successful implementation.

Detailed Description: The Specific Aims of this research are to: (i) Determine the effect of a pediatric direct admission system on timeliness of healthcare provision (the investigator's primary outcome), family experience of care, and rates of clinical deterioration compared to hospital admission beginning in the ED; (ii) Identify the pediatric populations and conditions that experience the greatest benefits from direct admission; and (iii) Through interviews with key informants, identify barriers to and facilitators of implementing standardized direct admission processes.

To achieve these Aims, a stepped-wedge cluster randomized controlled trial at three geographically diverse hospitals in the United States will be conducted, randomizing primary and urgent care practices in the hospitals' catchment area to cross over to the direct admission intervention at four time points. Linear models with random effects for clusters and time period fixed effects will be used to evaluate outcomes associated with the direct admission intervention. To examine for heterogeneity of treatment effects, interactions between direct admission and a priori-specified subgroups will be examined.

Recruitment & Eligibility

Inclusion Criteria

Not provided

Exclusion Criteria

Not provided

Arm && Interventions

Group	Intervention	Description
Direct Admission	Direct admission	Referring providers contact the hospital to arrange for a child to be admitted directly into the pediatric hospital medicine unit.
ED Admission	ED admission	Children initially present at the Emergency Department and are then admitted to the pediatric hospital medicine unit.

Primary Outcome Measures

Name	Time	Method
Timeliness of Clinical Care - Initial Therapeutic Management	within 6 hours of hospital admission	Length of time from arrival at the hospital until time of first antibiotics, IV placement, fluid administration, or other medications
Timeliness of Clinical Care - Initial Clinical Assessment	within 6 hours of hospital admission	Length of time from arrival at the hospital until first time when at least 3 vital signs were documented; if missing, time of initial brief nursing assessment
Timeliness of Clinical Care - Initial Diagnostic Testing	within 6 hours of hospital admission	Length of time from arrival at the hospital until time of initial labs and/or imaging, including "standing orders" for diagnostic testing in emergency departments

Secondary Outcome Measures

Name	Time	Method
Number of Participants With Clinical Deterioration	within 6 hours of arrival on the inpatient unit	Transfer for pediatric intensive care or rapid response calls
Pediatric Hospitalization Admission Survey of Experience (PHASE)	Within 72 hours of hospital admission	Standardized closed-ended survey questions regarding parent-reported experience of hospital admission with respect to the admission process, communication with families, communication between providers, and the hospital space; composite measure on 0-1 scale, with higher scores indicating better family experience

Locations (3): Nationwide Children's Hospital
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Columbus, Ohio, United States
UPMC Children's Hospital of Pittsburgh
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Pittsburgh, Pennsylvania, United States
Providence Regional Medical Center - Everett
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Everett, Washington, United States