Skipping the ED: How Some Pediatric Patients Benefit from Direct Hospital Admission from Primary Care with Dr. Sylvia Choi and Dr. Allison Fleischer

Paul C. Gaffney Division of Pediatric Hospital Medicine | Pitt Pediatrics

Direct admission to hospital: an alternative approach to hospitalization | NIH National Library of Medicine

Direct admission to hospital: AAP policy addresses benefits, challenges | American Academy of Pediatrics

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Voiceover: This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgements when advising their patients. Patients in need of medical care should consult their personal care provider. Welcome to "That's Pediatrics", where we sit down with physicians, scientists, and experts to discuss the latest discoveries and innovations in pediatric healthcare.

Dr. Arvind Srinath: From UPMC Children's Hospital of Pittsburgh, welcome to That's Pediatrics. I'm Arvind Srinath, Associate Professor for Pediatrics from the Division of Pediatric Gastroenterology. Today we have the honor of working with two incredible physicians, Dr. Sylvia Choi and Allison Fleischer, who are here to talk about direct admissions from primary care. I want to give a little background on both of our experts before we get started here.

Dr. Sylvia Choi joined the Paul C. Gaffney Division of Pediatric Hospital Medicine in 1998, following completion of her pediatric residency here, including a year spent as chief resident.

Since then, she has dedicated herself as a clinician educator to advancing the care of hospitalized children, as well as providing robust learning opportunities for trainees and clinicians in our hospital and the surrounding area. Dr. Choi enjoys teaching, with a focus on communication skills and has been involved with resident and faculty education as well as national workshops.

She is currently co-investigator, along with Dr. Fleischer, and clinical co-lead of a Patient Centered Outcomes Research Initiative, which I'm going to abbreviate as PCORI, multi-center study, comparative study, addressing comparative effectiveness of direct admission and admission through emergency departments for children, which we're going to get into a little bit today. Dr. Choi practices full-time as a board-certified pediatric hospitalist, and she is currently the vice chair of Faculty Affairs for Pitt Department of Pediatrics in our hospital and president of the Children's Hospital Professional Staff.

Dr. Fleischer also joined the Paul C. Gaffney Division of Pediatric Hospital Medicine in 2014 after completing her residency here, as well. She's currently practicing full-time as a partial nocturnist for the division's limited teaching service. Dr. Fleischer has collaborated with the subspecialty colleagues to develop clinical effectiveness guidelines for evaluation and management of a variety of conditions, including acute, unilateral cervical lymphadenitis, Kawasaki disease, fever in infants under 60 days of age, and falls in the hospital. She also, as I mentioned, with Dr. Choi, is a co-investigator for the PCORI study, and she enjoys sharing her knowledge and experience with senior pediatric residents who elect to rotate on limited teaching services. Welcome to both of you.

Dr. Sylvia Choi: Thank you, Arvind.

Dr. Allison Fleischer: Thanks for having us.

Dr. Srinath: Can I just get started with a little background from both of you? Can you both share with us your path to getting involved in the Division of Pediatric Hospital of Medicine and how your interests morphed into that of direct admissions?

Dr. Choi: Sure. I became a pediatric hospitalist before there sort of was a specialty known as pediatric hospital medicine. I've always really enjoyed taking care of sick kids, yet not so sick that they would be in the ICU setting. And I love collaborating with multiple different specialties. So for me, pediatric hospital medicine was exactly the right fit. And most of our children who get admitted come through the emergency department, so looking at ways that we might be able to streamline the admission process and have some come as a direct admission was really engaging and interesting to me.

Dr. Srinath: That's amazing, and so well put, too, in terms of your interests. Dr. Fleischer?

Dr. Fleischer: Yeah, I also joined, well quite a bit later than Sylvia, once pediatric hospital medicine was really an established specialty. So in 2014, following residency, after I was spending quite a bit of time as a resident in the exploring pathway, not knowing what I wanted to do after graduation, but always enjoying my time on the inpatient pediatric rotations and, like Sylvia said, loving taking care of sick patients admitted to the hospital. So I've been on the “Orange Team” or our limited teaching service for my entire career, being on the front lines of accepting those direct admissions and admitting those patients. That was part of the reason I was really excited to get involved in this study.

Dr. Srinath: Fantastic. Thank you both for sharing that. Can we just start with a simple question, just for my understanding? What is a direct admission?

Dr. Choi: Interestingly enough, most children who become ill come to the emergency department and that's where they get diagnosed and admitted for further treatment. But about one in four kids who are admitted are admitted as a direct admission where they bypass the emergency department and go directly from usually their primary care physician's office, sometimes an urgent care center, directly to an inpatient bed. That's what we mean by a direct admission. It's sort of a weird nomenclature.

Dr. Srinath: Got it. Got it. And what are some advantages of a direct admission as opposed to children going through the ER versus disadvantages, too?

Dr. Fleischer: One special population I would highlight would be a neonate with hyperbilirubinemia. Those patients, many times, are at home when that bilirubin result comes back and their pediatrician arranges a direct admission to the inpatient floor, allowing that newborn to bypass the emergency department where they may get exposed to many, many other illnesses that we know are not something that we want to expose a brand-new baby to. So that's one example of an advantage of bypassing the emergency department for a patient that we know requires inpatient care.

Dr. Srinath: Got it.

Dr. Choi: And then, from a utilization review standpoint, they don't have to go through the emergency department, which saves the family a charge. It helps with throughput for our emergency department, which, as you know, has been very, very busy within these last year with many patients. And if there's someone who needs to be admitted and you know they're going to be admitted, if they don't need emergency stabilization, it can actually be cost savings for everybody if they go directly to an inpatient bed.

Dr. Srinath: You two are reading my mind in terms of my next series of questions here, and that's a great segue here is the difference between a direct admission versus coming in through an ER. And I imagine patients and families listening, and community pediatricians, are trying to differentiate. Is there a certain window where you think, "Okay, if a child needs interventions within an X period of time, they should probably go through the ER versus a direct admission?”

Dr. Fleischer: Right, and that's exactly what the PCORI-funded study that we both participated in was aiming to find. We all hypothesized that direct admission for certain conditions would be advantageous for the patient, for their family, for the system, for some of the reasons we mentioned. But that's actually not really been studied widely in children. And I think many people have concerns about the safety of a direct admission process and also identifying what conditions would be most amenable to direct admission because, obviously, as you mentioned, the patient that requires immediate intervention or immediate stabilization is not a patient that traditionally would be viewed as appropriate for direct admission, so that was one of the study aims. We really wanted to find out what diagnoses might be most appropriate for directed admission and also study the outcomes, like timeliness of care, any adverse events or unexpected ICU transfers, which, fortunately, during our three-year study period, we had zero adverse-

Dr. Srinath: Wow. That's fantastic.

Dr. Fleischer: ... events, zero unplanned ICU transfers for our direct admissions.

Dr. Srinath: Sorry, you were going to say, Dr. Choi. I think your study is really addressing questions that I think a lot of us are thinking about, and I think a lot of us, as subspecialists, are trying to figure out, as well, in terms of triaging how we approach our patients and families we feel need to be admitted and need more acute care.

Can you describe a little bit more the overall goal of your PCORI-funded study? I have to work on the difference. And, two, the additional aims that the study had and if there's any preliminary findings, outside of the adverse events, or lack thereof, what there is so far.

Dr. Choi: Right. It was almost like a non-inferiority study, was to make sure that directly admitting a patient, just like Dr. Fleischer was saying, would not be harmful to the patient. So it wanted to have, specifically, would it be helpful to have written guidelines for diagnoses that would be appropriate for direct admission? Would it be helpful to have some sort of written communication for families? Because the acronym PCORI stands for Patient Centered Outcomes Research. So, really, what's interesting about that particular organization is that it always wants to have families and patients be involved, either in terms of the outcomes or monitoring the study, so that's one unique part about the PCORI funding.

Dr. Srinath: Interesting, interesting. Now, did you start off with certain admission criteria or guidelines? And, if so, are you able to share that with us?

Dr. Fleischer: Yeah, absolutely. That was one of the components that we were very directly involved with. This was a multi-center study. The primary investigator was Dr. JoAnna Leyenaar at Dartmouth, and then it was our hospital, Nationwide Children's Hospital, and then a community hospital affiliated with Seattle Children's. We actually had many planning meetings trying to come up with some target diagnoses that we felt would be patients who were likely to need more than a couple of hours of treatment in the hospital so that admission would actually be warranted but not so sick that they really needed that immediate intervention.

So we had eligibility criteria and then some example diagnoses that we educated our primary care practices on, but we really entertained a MedCall with a request for direct admission for almost anything. So in general, we did exclude patients under 60 days of age because of the potential that they would spike a fever on their way to Children's and require a different evaluation than maybe we had thought.

Also, a patient that was evaluated by their pediatrician. They needed to be seen in the primary care practice to be eligible for direct admission through our study. Really, we, in general, said it should be a patient that they have “failed” outpatient therapy. Some things have already been tried, maybe oral antibiotics for pneumonia or for a UTI that the child's unable to tolerate. And then a couple of other things. The patient really should be stable sitting in front of the PCP. I think that's a little bit obvious.

And then also that the family's in agreement with participating and coming to the hospital for direct admission, and understands that they're not going to go to the emergency department, they're going to go directly to an inpatient bed. They're likely going to spend the night, if not a little bit longer, and they need to go directly to Children's Hospital. So it's not a stop at McDonald's, stop at home, pack a bag, it's go directly from the pediatrician's office.

Those were kind of our eligibility criteria. And then we had a list of several diagnoses that we really felt would fit in with that model. So skin and soft tissue infection without abscess, because patients with abscesses often get their IND pretty quickly in the emergency department and then can usually go home. Patients with UTI, with pneumonia, dehydration, fever, other nonspecific viral illness, with some caveats for each of those diagnoses. Like hypoxemia, severe electrolyte derangements, we felt would not be appropriate for direct admission. So that's the model we tried to create and really disseminate to the PCP practices so that they knew what kinds of patients we were looking for.

Dr. Srinath: That's fantastic. Was there a certain window within when the pediatrician had to see these patients before being admitted to the hospital?

Dr. Fleischer: Not exactly. I would say usually the ideal model was that patients sitting right in front of them in their office and not taking their oral antibiotic for their UTI or not drinking well enough to sustain their hydration but not looking so ill that they needed immediate IV rehydration. That was the ideal scenario. I think probably there were a few times where we would get a MedCall for a patient that was seen a day or two prior, and if the scenario was still appropriate, we would accept them for direct admission. But, really, it was intended for the patient that was sitting in the office right then.

Dr. Srinath: Got it. And, getting along the lines of what you were saying, Dr. Choi, about how this is a patient-involved grant, a patient-centered grant, how disseminated was this study to patients and families and what role did patients and families have in, I'm sure, the negotiation process or decision-making process, but, really, were there any instances where patients or families asked the pediatrician first?

Dr. Choi: Yeah, that's a great question. I know that from an original study design that there were patients and parents on the advisory board for Dr. Leyenaar, the primary investigator who created the study. So they were involved even from the very beginning stages. And then we are super fortunate in Pittsburgh to have such a robust primary care network, between Children's Community Pediatrics, Allegheny Health Network Pediatrics, our Kids Plus Pediatrics practices. There are so many practices that participate because Children's Hospital is the quaternary care center for all of those pediatric groups.

We really have such wonderful relationships with all of these providers in the community, and so, between Dr. Fleischer and myself, we were able to partner with lead physicians from these main practices, and then they were sort of the partners in crime, as it were, and they helped us to disseminate the message and the study to all of their partners and then to their patients through that, so we were really fortunate to have them. We also then did have an advisory board here at our site that had patient-parent partners, which was great.

Dr. Srinath: That's incredible. Now, I'm trying to fathom the catchment area and the numbers. And to be honest, I feel like I'm standing on Jupiter and I'm just not getting it. Either of you have an idea of the catchment area for which your direct admission span and the number of patients that were admitted and the number of patients that was covering?

Dr. Fleischer: We sure do. I still remember, this was three years ago, but I sat on the CCP website and measured the mileage entering into my Google Maps, the mileage for probably 50 practices. We included about 45 practices, I think, and we did limit a radius of 40 miles from the hospital, just anticipating about an hour travel time to our campus in Lawrenceville would be appropriate, so as to not potentially have patients who would deteriorate on their way to Children's in their parents' vehicle. And, like Dr. Choi mentioned, we had practices from CCP, our general academic pediatrics, Kids Plus and AHN Pediatrics, and that was kind of the deciding factor was that 40-mile radius.

Dr. Srinath: Got it. Got it. I mean, that makes a lot of sense in terms of interventions and thinking about this. Now, I'm going to be perseverant, or you might think perseverance, on time. So, what is the time period, roughly, when I, as a pediatrician, say, "I think I need to directly admit this patient," and the time the patient gets on the floor?

Dr. Choi: That is a hard one. And that was one of the things that we were studying was the turnaround time. Because we know that there is inherent delay from the time you see the pediatrician and you present to the emergency department, are evaluated and treated in the emergency department and then admitted to the floor. Just like there would be time coming from the pediatrician's office and being "directly" admitted to the floor. "Directly admitted" makes it sound like, bam, it happens right away.

Dr. Srinath: You nailed it.

Dr. Choi: Yet we know that you have to come, you have to park, you have to go to the welcome desk, they have to call transport to accompany you to the room, the room has to be clean, so there are all those built-in times. We found, though, that it was actually a very fast turnaround time once the child arrived here at the door. They almost all, and I don't know offhand because that data analysis is not yet complete, but I do not believe there were any patients in the study that waited a significant amount of time in the lobby for a bed placement, let's say.

Dr. Srinath: Nice.

Dr. Fleischer: And that's one of the advantages of our MedCall system. We already had this MedCall system in place where we, as a pediatric hospitalists, would take calls, typically from outside emergency departments, regarding patients that they wanted to transfer here to Children's. And what we did was change that process and say, "Please, also direct any MedCalls from these pediatrician practices to us in PHM so that we can field those calls and decide if those patients are appropriate for direct admission."

That allowed us to be on a recorded line with a MedCall agent who had the ability to get the patient demographic information and also the added bonus of having the PFC on the line to be able to say, "Yes, I have a bed for that patient and here's where they will go," or to say, which I actually don't think happened during our study period, but to say, "We don't have a bed for that patient, they need to be directed to the emergency department."

Dr. Srinath: Got it. Got it. And that actually segues into communication because the continuity of care, I mean, you're spanning a 40-mile radius here and then you're coming into a hospital with, for lack of a better word, a ton of providers and multiple layers of providers, too, as being a teaching hospital. How does that communication work between a pediatrician and the care team caring for the patient on the floor?

Dr. Choi: They would call through MedCall, again, the UPMC-wide single number, the 692-5000 that people call to get a provider here at Children's to accept the patient. And they would provide all the necessary clinical information. And then the hospitalist physician that takes that call and "accepts" the patient to the hospital, then they work with the nursing leadership, that patient flow coordinator, who is typically a registered nurse who is in charge of placing the patients in the available and appropriate bed.

Most of our rooms are private rooms, as you know. We do have some shared rooms. Some of our floors have mainly immunocompromised children, such as the cancer floor, so where the patient gets placed requires a higher level of provider to make that decision. So our registered nurses who work as the patient flow coordinator typically will place the patient and then they would inform the hospital medicine physician, "Oh, the patient's going to go to X floor and the care team will be team Y." We have different care teams. Then that hospitalist physician would call the care team and give that verbal communication so that everyone would know about the patient. And that, like you said, is so important to make sure things don't fall through the cracks.

Dr. Srinath: That's amazing. And what a great layer. Dr. Fleischer, I was going to cut you off, but I was just going to say that that's an amazing layer and multidisciplinary or multi... I'm not using the right word here, but layers, which is fantastic, so the nurses are aware, too.

Dr. Fleischer: Right. And I was just going to add, that's really one of the things we all know in medicine, that communication is so important and, really, the goal was really to increase that communication between our community partners and our division of hospital medicine to make sure that all the intricacies of what has already happened for that patient as an outpatient get communicated to us as the inpatient team, which I think is lost many times when that patient is just referred into the emergency department. There's no direct line of communication to the inpatient team that will be caring for that child, so this is a way to add that portal of communication for the outpatient-to-inpatient transition.

Dr. Srinath: Got it. Got it.

Dr. Choi: The other interesting thing about communication is it started at the pediatrician's office because we actually had brochures at the office-

Dr. Srinath: Oh, nice.

Dr. Choi: ... that sort of told a family, "You are going to be directly admitted to the hospital. This is where you go, this is the map, this is where you park, this is where you walk. It's called the welcome desk. This is where you go, someone's going to meet you there. They're going to bring you up to your room. You're going to meet a nurse." It just helps smooth that process for the family, too, because I think that that, even setting up their expectations so they know what is going to happen is so important for their overall experience.

Dr. Srinath: Well, the last thing you need is, "Oh, my gosh, this process is in place and where do I even go? Where do I park?" And that being a limiting factor when, as a parent or a caretaker, you're concerned about, understandably, your child's wellbeing. That noise is helpful to get out of the way.

Dr. Choi: Absolutely.

Dr. Srinath: Can I ask you, I understand enrollment is now complete for your study, is the process of direct admissions changing since enrollment for this study, or have any changes been made since enrollment, or is it too soon to tell?

Dr. Fleischer: I think it's a little too soon to tell. Like Dr. Choi said, we still are certainly accepting patients for direct admission and all of the PCP practices that we've recruited throughout this study are still aware of the process. One of the things that we hope to do is certainly, once the findings are made available and published, we want to share that with our PCP partners and really revamp our program. And one of the things we had thought about was making those materials, those brochures that we mentioned, available on the Infonet so that our PCP partners can print out a brochure that explains what direct admission is or what the emergency department referral process looks like.

We also have a brochure that talks about going directly to the ED. So that's something that we really hope to do in the future, is reeducate our primary care practices, and our own division of hospital medicine, that this process exists and that it's been studied and at least certainly no negative outcomes. But I think that's what we hope to do next.

Dr. Srinath: That's amazing. And I'll just close with, again, circling back to the patient-centered approach for this study, as well as, naturally, what we do, what feedback have you received from patients and families?

Dr. Choi: Families that were part of this study that engaged in an interview process afterwards were all very uniformly positive about not having to go through the emergency department because their child was stable enough to come directly to the floor and they all found that it was less hassle. It was certainly easier for them overall because they didn't have to have that prolonged wait in the emergency department and they felt like the care they received was excellent. So we've had very good positive feedback.

Dr. Srinath: That's amazing. Well, hey, thank you, Dr. Choi and Dr. Fleischer, for the opportunity to learn about the direct admissions process, the amazing study you two were co-investigators on, and touching upon outcomes and advantages were all positives about this process that we do at Children's. So thank you.

Dr. Fleischer: Thanks for having us.

Dr. Choi: Yeah, thank you for letting us share this.

Dr. Srinath: Absolutely.

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