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

Patient-Centered Outcomes Research Institute, Nationwide Children's Hospital, Providence Regional Medical Center, University of Pittsburgh, Dartmouth College, Seattle Children's Hospital

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.

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.

Referring providers contact the hospital to arrange for a child to be admitted directly into the pediatric hospital medicine unit.

Children initially present at the Emergency Department and are then admitted to the pediatric hospital medicine unit.

Process of pediatric admission is through admission directly into the pediatric hospital medicine unit

Standardized closed-ended survey questions re. 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 0-100 scale, with higher scores indicating better family experience

Inclusion Criteria Child has one of the following presenting diagnoses: gastroenteritis dehydration skin and soft tissue infection urinary tract infection/pyelonephritis pneumonia viral infection not otherwise specified influenza Exclusion Criteria Ineligible children include those: with planned admissions (i.e., chemotherapy) admitted to non-pediatric hospital medicine services (i.e., intensive care) transferred from other hospitals

Leyenaar JK, McDaniel CE, Acquilano SC, Schaefer AP, Bruce ML, O'Malley AJ. Comparative effectiveness of direct admission and admission through emergency departments for children: a randomized stepped wedge study protocol. Trials. 2020 Nov 30;21(1):988. doi: 10.1186/s13063-020-04889-9.