Short stay facilities: the future of efficient paediatric emergency services

Interventions to reduce acute paediatric hospital admissions: a systematic review

BACKGROUND

Admission rates are rising despite no change to burden of illness, and interventions to reduce unscheduled admission to hospital safely may be justified.

OBJECTIVE

To systematically examine admission prevention strategies and report long-term follow-up of admission prevention initiatives.

DATA SOURCES

MEDLINE, Embase, OVID SP, PsychINFO, Science Citation Index Expanded/ISI Web of Science, The Cochrane Library from inception to time of writing. Reference lists were hand searched.

STUDY ELIGIBILITY CRITERIA

Randomised controlled trials and before-and-after studies.

PARTICIPANTS

Individuals aged <18 years.

STUDY APPRAISAL AND SYNTHESIS METHODS

Studies were independently screened by two reviewers with final screening by a third. Data extraction and the Critical Appraisals Skills Programme checklist completion (for risk of bias assessment) were performed by one reviewer and checked by a second.

RESULTS

Twenty-eight studies were included of whom 24 were before-and-after studies and 4 were studies comparing outcomes between non-randomised groups. Interventions included referral pathways, staff reconfiguration, new healthcare facilities and telemedicine. The strongest evidence for admission prevention was seen in asthma-specific referral pathways (n=6) showing 34% (95% CI 28 to 39) reduction, but with evidence of publication bias. Other pathways showed inconsistent results or were insufficient for wider interpretation. Staffing reconfiguration showed reduced admissions in two studies, and shorter length of stay in one. Short stay admission units reduced admissions in three studies.

CONCLUSIONS AND IMPLICATIONS

There is little robust evidence to support interventions aimed at preventing paediatric admissions and further research is needed.

The association between opening a short stay paediatric assessment unit and trends in short stay hospital admissions

Background

Many inpatient facilities in Scotland have opened short stay paediatric assessment units (SSPAU) which are clinical areas separate from the usual inpatient ward area and these are where most short stay (also called zero day) admissions are accommodated. Here we describe the effect of opening short stay paediatric assessment units (SSPAU) on the proportion of zero day admissions relative to all emergency admissions.

Methods

Details of all emergency medical paediatric admissions to Scottish hospitals between 2000 and 2013 were obtained, including the number of zero day admissions per month and health board (i.e. geographic region). The month and year that an SSPAU opened in each health board was provided by local clinicians.

Results

SSPAUs opened in 7 health boards, between 2004 and 2012. Health boards with an SSPAU had a slower rise in zero day admissions compared to those without SSPAU (0.6% per month [95% CI 0.04, 0.09]. Across all 7 health boards, opening an SSPAU was associated with a 13% [95% CI 10, 15] increase in the proportion of zero day admissions. When considered individually, zero day admissions rose in four health boards after their SSPAU opened, were unchanged in one and fell in two health boards. Independent of SSPAUs opening, there was an increase in the proportion of all admissions which were zero day admissions (0.1% per month), and this accelerated after SSPAUs opened.

Conclusion

Opening an SSPAU has heterogeneous outcomes on the proportion of zero day admissions in different settings. Zero day admissions could be reduced in some health boards by understanding differences in clinical referral pathways between health boards with contrasting trends in zero day admissions after their SSPAU opens.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06541-x.

Changing characteristics of hospital admissions but not the children admitted-a whole population study between 2000 and 2013

There are increasing numbers of emergency medical paediatric admissions. Our hypothesis was that characteristics of children and details of their emergency admissions are also changing over time. Details of emergency admissions in Scotland 2000-2013 were analysed. There were 574,403 emergency admissions, median age 2.3 years. The age distribution, proportion of boys and socioeconomic status of children admitted were essentially unchanged. Emergency admissions rose by 49% from 36/1000 children per annum to 54/1000 between 2000 and 2013. Emergency admissions that were discharged on the same day rose by 186% from 8.6/1000 to 24.6/1000. The mean duration of emergency admission fell from 1.7 to 1.0 days. The odds for an emergency admission with upper respiratory infection, "viral infection", tonsillitis, bronchiolitis and lower respiratory tract infection all rose. In contrast the odds for an emergency admission with asthma and gastroenteritis fell.

CONCLUSIONS

The demographics of children with emergency admissions have not changed substantially but characteristics of admissions have changed considerably, in particular admissions which are short stay and due to respiratory infection are much more common. The fall in the absolute number of children with some acute medical diagnoses suggests that the rise in admissions is not necessarily inexorable. What is Known: • Emergency admission prevalence is rising in many countries across Europe. What is New: • Our paper is the first to comprehensively analyse emergency medical paediatric admissions by exploring how characteristics of admissions and the children admitted have changed over time for a whole population. • The "take home message" is that whilst characteristics of emergency admissions have changed (e.g. number, duration of stay, readmissions, diagnoses), the characteristics of the children have not changed.

Alternatives to ward admission from the emergency department

There is ever-increasing pressure on hospital resources in general and emergency departments (ED) in particular. At the same time, there is increasing recognition that traditional inpatient ward-based care is not necessary for the majority of children presenting to the ED with acute illness, and that there are patient, family and hospital benefits to pursuing other options. Here, we describe alternative pathways for children presenting to the ED, including short stay and observational medicine, hospital-in-the-home and non-admission enhanced care, in other words, additional management practices or pathways for children who are discharged from the ED. We discuss the principles, models and practical considerations involved in each of these.

Specialist home-based nursing services for children with acute and chronic illnesses

BACKGROUND

Specialist paediatric home-based nursing services have been proposed as a cost-effective means of reducing distress resulting from hospital admissions, while enhancing primary care and reducing length of hospital stay. This review is an update of our original review, which was published in 2006.

OBJECTIVES

To evaluate specialist home-based nursing services for children with acute and chronic illnesses.

SEARCH METHODS

We searched the following databases in February 2012: the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library 2012 Issue 2, Ovid MEDLINE, EMBASE, PsycINFO, CINAHL and Sociological Abstracts. We also searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of children from birth to age 18 years with acute or chronic illnesses allocated to specialist home-based nursing services compared with conventional health care. Outcomes included utilisation of health care, physical and mental health, satisfaction, adverse health outcomes and costs.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data from the studies independently and resolved any discrepancies by recourse to a third author. Meta-analysis was not appropriate because of the clinical diversity of the studies and the lack of common outcome measures.

MAIN RESULTS

We screened 4226 titles to yield seven RCTs with a total of 840 participants. Participants, interventions and outcomes were diverse. No significant differences were reported in health outcomes; two studies reported a reduction in the hospital stay with no difference in the hospital readmission rates. Three studies reported a reduction in parental anxiety and improvement in child behaviours was reported in three studies. Overall increased parental satisfaction was reported in three studies. Also, better parental coping and family functioning was reported in one study. By contrast, one study each reported no impact on parental burden of care or on functional status of children. Home care was reported as more costly for service providers with substantial cost savings for the family in two studies, while one study revealed no significant cost benefits for the family.

AUTHORS' CONCLUSIONS

Current research does not provide supporting evidence for a reduction in access to hospital services or a reduction in hospital readmission rate for children with acute and chronic illnesses using specialist home-based nursing services; however, the only summary finding across a few studies was that there is a significant decrease in length of hospitalisation. The preliminary results show no adverse impact on physical health outcomes and a number of papers reported improved satisfaction with home-based care. Further trials are required, measuring health, satisfaction, service utilisation and long-term costs.

Setting up a Paediatric Rapid Access Outpatient Unit: views of general practice teams

Background

Rapid Access Outpatient Units (RAOUs) have been suggested as an alternative to hospital inpatient units for the management of some acutely unwell children. These units can provide ambulatory care, delivered close to home, and may prevent unnecessary hospital admission. There are no qualitative data on the views of primary care practitioners regarding these types of facilities. The aim of the study was to explore the opinions of primary care practitioners regarding a newly established RAOU.

Methods

The RAOU was established locally at a district general hospital when inpatient beds were closed and moved to an inpatient centre, based six miles away at the tertiary teaching hospital.

Qualitative, practice based group interviews with primary care practitioners (general practitioners (GPs), nurse practitioners and practice nurses) on their experiences of the RAOU. The data collection consisted of three practice based interviews with 14 participants. The interviews were recorded and transcribed verbatim. Thematic content analysis was used to evaluate the data.

Results

There was positive feedback regarding ease of telephone access for referral, location, and the value of a service staffed by senior doctors where children could be observed, investigated and discharged quickly. There was confusion regarding the referral criteria for the assessment unit and where to send certain children. A majority of the practitioners felt the utility of the RAOU was restricted by its opening hours. Most participants felt they lacked sufficient information regarding the remit and facilities of the unit and this led to some uneasiness regarding safety and long term sustainability.

Conclusion

Practitioners considered that the RAOU offered a rapid senior opinion, flexible short term observation, quick access to investigations and was more convenient for patients. There were concerns regarding opening hours, safety of patients and lack of information about the unit's facilities. There was confusion about which children should be sent to the unit. This study raises questions regarding policy in regard to the organisation of paediatric services. It highlights that when establishing alternative services to local inpatient units, continual communication and engagement of primary care is essential if the units are to function effectively.

Review of a paediatric emergency department observation unit

AIM

To review the function of an emergency department paediatric observation unit.

METHOD

A retrospective observational study reviewing the activity of the observation unit for 12 months

RESULTS

During 12 months, 4446 children were admitted to the observation unit and 76% were discharged home: usually within 8 hours. The average admission rate was 12 children in 24 hours. The commonest causes for children being admitted to the observation unit were respiratory problems and gastroenteritis or dehydration.

CONCLUSION

The emergency paediatric observational unit was used to assess and treat children with a variety of conditions. This enabled many children to be managed in the emergency department rather than being admitted to the paediatric wards.

A reduction in hospitalization, length of stay, and hospital charges for croup with the institution of a pediatric observation unit

OBJECTIVES

The aim of the study was to assess the impact of an observation unit (OU) on hospital resource utilization for patients with croup.

METHODS

A retrospective review with the use of a historical control was performed for 2 years of nondischargeable emergency department (ED) patients with croup.

RESULTS

The total number of ED patients with croup was 694 in the first year and 789 in the second year. Hundred seventy patients were enrolled, 66 in the first year and 104 in the second year (76 admitted to the OU and 33 admitted to the ward). There was a reduction in the ward admission rate from 9.5% to 4.2% (P < .0001) from the first to the second year. The median length of stay for the pre-OU group was 27.2 vs 21.3 hours for the post-OU group (P = .03). The median charge for the pre-OU group was $1685 vs $1327 for the post-OU group (P = .03).

CONCLUSIONS

After the introduction of the OU, hospitalization was reduced, and the overall resource utilization for the care of nondischargeable ED patients with croup was reduced.

Specialist home-based nursing services for children with acute and chronic illnesses

BACKGROUND

Specialist paediatric home-based nursing services have been proposed as a cost-effective means of reducing trauma resulting from hospital admissions, while enhancing primary care and reducing length of hospital stay.

OBJECTIVES

To evaluate specialist home-based nursing services for children with acute and chronic illnesses.

SEARCH STRATEGY

Electronic searches were made of CENTRAL (Cochrane Central Register of Controlled Trials) 2005 (Issue 2); MEDLINE (1966 to August 2005); EMBASE (1980 to August 2005); PsycINFO (1887 to August 2005); CINAHL (1982 to August 2005); Sociological Abstracts (1963 to August 2005). Optimally sensitive search strategies for randomised controlled trials (RCTs) were combined with medical subject headings and text words specific for ambulatory paediatrics, nursing outreach and 'hospital in the home', and no language restrictions were applied.

SELECTION CRITERIA

RCTs of children aged 0-18 with acute or chronic illnesses allocated to specialist home-based nursing services compared with conventional medical care. Outcomes included utilisation of health care, physical and mental health, satisfaction, adverse health outcomes and costs.

DATA COLLECTION AND ANALYSIS

Meta-analysis was not appropriate because of the clinical diversity and lack of common outcomes measures

MAIN RESULTS

1655 titles yielded 5 RCTs with a total of 771 participants. Participants, interventions and outcomes were diverse. No significant differences were reported in health outcomes; two studies reported improvements in child and parental anxiety; one study reported no significant difference in readmissions; two studies reported significantly fewer bed days; increased satisfaction was reported ; home care was more costly for service providers, but less expensive for parents.

AUTHORS' CONCLUSIONS

While current research does not provide definitive support for specialist home-based nursing services in reducing access to hospital services or length of stay, preliminary results show no adverse impact on physical health outcomes and a number of papers reported improved satisfaction with home-based care. Further trials are required, measuring health, satisfaction, service utilisation and long-term costs.

A prospective cohort study comparing hospital admission for gastro-enteritis with home management

OBJECTIVES

To compare physical and psychological outcomes in children presenting at Accident and Emergency Departments (A&E), diagnosed with gastro-enteritis and admitted to hospital with those of a similar age, sex and severity of illness discharged home. The physical and psychological well-being of children in these two groups, in the month after the episode, were compared as was further use of health care services.

DESIGN

A prospective cohort study.

METHODS

A comparison of 116 children aged 1-6 years with gastro-enteritis, presenting at A&E over a 6 months period. Admitted children were compared with children discharged, of a similar age, sex and illness severity (triage score) with follow-up at 1 week and 1 month. Clinical history, psychosocial factors, investigations and outcomes were recorded at presentation and physical, psychological and family outcomes at 1 week and 1 month.

RESULTS

Of 116 children, 112 (97%) completed the study (56 in each group). No differences were detected in psychosocial factors, socio-economic status, family factors, time of arrival at A&E or waiting times. Parental perception of illness was greater in the admitted group (P < 0.005), but was recorded after the decision on admission was made. At 1 week follow-up admitted children had increased separation anxiety compared with children who were discharged (P < 0.05), but this difference disappeared at 1 month. Clinical outcomes were the same for both groups, although admitted children had more investigations (91% vs. 39%). Parents were equally satisfied with their child's treatment, but one-third of children in both groups sought further consultation with a health professional in the following week.

CONCLUSIONS

There is no statistically significant difference in socio-demographic data, time of arrival at A&E, waiting times, clinical and psychosocial outcomes in children with acute gastro-enteritis admitted to hospital compared with a group of children of similar age, gender and severity of illness managed at home. However, parents seek reassurance and follow-up of acutely ill children, even if the child is admitted to hospital, which has service and resource implications.

Actividad de una unidad de observación en un servicio de urgencias de un hospital terciario: dos años de experiencia

OBJECTIVES

To describe the characteristics of the activity of a short stay observation unit (SSOU) in a tertiary hospital, and to analyze its influence on the hospitalization rate.

MATERIAL AND METHODS

The activity of the SSOU during the first 2 years after opening is described. Descriptive variables were registered. Hospitalization activity during the first 5 months after opening the unit was compared with the activity during the same period in the previous year.

RESULTS

From June 1, 2001 to May 31, 2003, 74,989 patients were admitted to the emergency department (ED) and 2,438 (3.25 %) were transferred to the SSOU. The mean age of the patients was 64.55 months. The mean length of stay was 5 hours and 50 minutes. The main discharge diagnoses were gastrointestinal disease (30.2 %), accidents (15 %), respiratory illness (12.5 %) and febrile syndrome (9.8 %). The hospitalization rate in patients admitted to the ED was 5.8 % from June 1, 2000 to October 1, 2000 and was 4.28 % in the same period in 2001. The mean diagnosis-related group (DRG)-weight was 0.8648 in 2000 and was 0.9078 in 2001. Total weight was 680.66 in 2000 and 495.69 in 2001, allowing an approximate saving of 329,162 Euros.

CONCLUSIONS

The opening of the SSOU has been useful in the assessment and treatment of common childhood diseases and has helped reduce the hospitalization rate, increase the complexity of inpatients and lower costs.

Hospital based alternatives to acute paediatric admission: a systematic review

AIMS

To synthesise published evidence of the impacts of introducing hospital based alternatives to acute paediatric admission.

METHODS

Systematic review of studies of interventions for children with acute medical problems. Main outcome measures were: admission or discharge, unscheduled returns to hospital, satisfaction of parents and general practitioners, effects on health service activity, and costs.

RESULTS

Twenty five studies were included: one randomised controlled trial, 23 observational or cross-sectional studies, and one qualitative study. Many studies were of uncertain quality or were open to significant potential bias. About 40% of children attending acute assessment units in paediatric departments, and over 60% of those attending acute assessment units in A&E departments, do not require inpatient admission. There is little evidence of serious clinical consequences in children discharged from these units, although up to 7% may subsequently return to hospital. There is some evidence that users are satisfied with these services and that they are associated with reductions in inpatient activity levels and certain hospital costs. Evidence about the impact of urgent outpatient clinics is very limited.

CONCLUSIONS

Current evidence supports a view that acute paediatric assessment services are a safe, efficient, and acceptable alternative to inpatient admission, but this evidence is of limited quantity and quality. Further research is required to confirm that this type of service reorganisation does not disadvantage children and their families, particularly where inpatient services are withdrawn from a hospital.

[Effectiveness of a short-stay observation unit in a pediatric emergency department]

Short-Stay Observation Units (SSOUs) in paediatric emergency departments are effective in reducing inpatient admissions but can also generate excessive short-stay hospitalisations. The aim of the study was to evaluate both these consequences and the different missions of SSOUs.

METHODS

This prospective study included all children admitted in a 10-bed-medico-surgical SSOU of a tertiary-care paediatric emergency department from September 4, to October 31, 2001. At the time of SSOU admission, the physician indicated the purpose of the admission and which decision he would have made in the absence of a SSOU.

RESULTS

Five hundred and nine children (median age = 4 years, chronic disease: 26%, trauma: 34%) were included, accounting for 15% of admissions. The mean length of stay was 14 +/- 8h. The decision in the absence of a SSOU would have been: inpatient hospitalization (77%), transfer to another hospital in the absence of inpatient room vacancy (7%), discharge home (10%), prolonged waiting in the emergency ward (4%), do not know or not indicated (2%). The SSOU admission was deemed appropriate in 81%: discharge home within 24h was likely in 65% and the final orientation of the child was uncertain in 16%. The admission was debatable in 13% and inappropriate in 6%. Sixty six per cent of children were discharged home.

CONCLUSION

The SSOU reduced inpatient hospitalisations, generated few inappropriate short stay hospitalisations, and seemed particularly efficient for paediatric diseases. Proposed indicators should allow inter-hospital comparisons.

A seven year experience of medical emergencies in the assessment unit

AIMS

To analyse retrospectively all referrals to the assessment unit during a seven year period, to determine their sources and destination.

METHODS

All referrals over the seven year period were analysed. Parental satisfaction was determined using a questionnaire in some of the patients. The disease pattern and the investigations performed were determined. The community nurses' working hours and type of work done were analysed.

RESULTS AND CONCLUSIONS

A total of 43 496 children were seen in the unit. Over 65% of the patients were referred by the general practitioners; 13 517 (34.2%) of those referred to the unit were discharged directly from the unit. Respiratory disorders and gastrointestinal problems were commonly seen. The children discharged from the unit did not have significantly more tests done on them. Most of the parents whose children were discharged from the unit were happy to be managed at home. The community nurses attended many children who needed intravenous therapy and advice on fluid rehydration. Community nurses reduce admission to the wards by working with other members in the assessment unit. This in turn provides a single point of entry and bridges the gap between primary and secondary care. We suggest recommendations on setting up such a unit.

Contemporary issues in the care of sick children and their families

This article considers the response of children's nurses to contemporary change in the management of sick children and their families throughout the last decade. In recognizing the rich and diverse history of children's nursing the impact of those factors which have led to the development of operational strategies to manage children's services will be considered. The quest, not always successful, to coordinate care as a seamless web of services to children and their families will be investigated, as will the role dimensions encompassed by specialist children's nurses and their interface with interprofessional colleagues. A range of nurse-led services in a variety of contemporary child health settings will be explored.

[Assessing the cost of the first episode of bronchiolitis]

BACKGROUND

Each year, a quarter of the children younger than 24 months has respiratory syncytial virus bronchiolitis. The morbidity among high-risk infants and the possible association with the development of asthma lead to propose preventive measures whose cost-effectiveness relationship is unknown. The present work was aimed at measuring costs of a first attack of bronchiolitis.

METHOD

For children less than two years visited in the emergency department, direct and indirect costs were measured according to the 'Sécurité Sociale' prices. Associated morbidity, the management of care (inpatient versus outpatient), outpatients' outcome two weeks after the visit, socioeconomic data were recorded.

RESULTS

One hundred eighty three children have been studied. The length of stay for 40 hospitalizations was 7.6 +/- 4.3 days. Direct costs were 37,200 +/- 22,000 FF for inpatients, and 1286 +/- 633 F for outpatients. For 113 outpatients' families, indirect costs were 49 working days lost. The way the child was looked after and the unemployment rate in the study were similar to data provided by the National Institute of Statistics and Economic Studies.

CONCLUSION

Because of the variability of the hospitalization rate from one setting to another, overall costs of the epidemic cannot be evaluated. For the policymaker, the greatest costs come from the outpatient care. Others studies will be necessary to evaluate the price of future preventive measures.

A short stay or 23-hour ward in a general and academic children's hospital: are they effective?

OBJECTIVE

We evaluated the usefulness of a short stay or 23-hour ward in a pediatric unit of a large teaching hospital, Westmead Hospital, and an academic Children's hospital, The New Children's Hospital, to determine if they are a useful addition to the emergency service.

METHODS

This is a descriptive comparison of prospectively collected data on all children admitted to the short stay ward at Westmead Hospital (WH) during 1994 and the short stay ward at the New Children's Hospital (NCH) during 1997-98. These hospitals service an identical demographic area with the latter (NCH) a tertiary referral center. The following outcome measures were used: length of stay, appropriateness of stay, rate of admission to an in-hospital bed, and rate of unscheduled visits within 72 hours of discharge. Adverse events were reported and patient follow-up was attempted at 48 hours after discharge in all cases.

RESULTS

The short stay ward accounted for 10.3% (Westmead Hospital) and 14.7% (New Children's Hospital) of admissions, with 56% medical in nature, 30% surgical, and the remainder procedural or psychological. Admission patterns were similar, with asthma, gastroenteritis, convulsion, pneumonia, and simple surgical conditions accounting for most short stay ward admissions. The short stay ward increased hospital efficiency with an average length of stay of 17.5 hours (Westmead Hospital) compared to 20.5 hours (New Children's Hospital). The users of the short stay ward were children of young age less than 2 years, with stay greater than 23 hours reported in only 1% of all admissions to the short stay ward. The rate of patient admission to an in-hospital bed was low, (4% [Westmead Hospital] compared to 6% [New Children's Hospital]), with the number of unscheduled visits within 72 hours of short stay ward discharge less than 1%. There were no adverse events reported at either short stay ward, with parental satisfaction high. The short stay ward was developed through reallocation of resources from within the hospital to the short stay ward. This resulted in estimated savings of $1/2 million (Westmead Hospital) to $2.3 million (New Children's Hospital) to the hospital, due to more efficient bed usage.

CONCLUSION

This data demonstrates the robust nature of the short stay ward. At these two very different institutions we have shown improved bed efficient and patient care in a cost-effective way. We have also reported on greater parental satisfaction and early return of the child with their family to the community.

Unscheduled return visits within 72 hours to an assessment unit

Unscheduled return visits were looked at to determine the quality of care and safety of patients in a paediatric assessment unit. The reasons for unscheduled return visits were also investigated. Two per cent of patients discharged from the unit returned, the main reason being parental perception of illness. There were only two patients re-referred by their family doctor. These findings have implications for clinical care and education.

Parental and professional perception of need for emergency admission to hospital: prospective questionnaire based study

AIM

To compare views of parents, consultants, and general practitioners on severity of acute illness and need for admission, and to explore views on alternative services.

METHOD

Prospective questionnaire based study of 887 consecutive emergency paediatric admissions over two separate three week periods in summer and winter of five Yorkshire hospitals, combined with a further questionnaire on a subsample.

OUTCOME MEASURES

Parental scores of need for admission and parent and consultant illness severity scores out of 10. Consultant judgment of need for admission. Alternatives to admission considered by consultants and, for a subsample, by parents and family GP.

RESULTS

Ninety nine per cent of parents thought admission was needed. Parents scored need for admission more highly than severity of illness with no association observed between severity and presenting problem or diagnosis. High parental need score was associated with a fit, past illness, and length of stay. Consultant illness severity scores were skewed to the lower range. Consultants considered admission necessary in 71%, especially for children aged over 1 year, presentation with breathing difficulty or fit, and after a longer stay. More admissions in the evening were considered unnecessary as were admissions after longer preadmission illness, gastroenteritis, or upper respiratory tract infection. Of a subsample of parents, 81% preferred admission during the acute stage of illness even if home nursing had been available. Similar responses were obtained from GPs. Alternative services could have avoided admission for 19% of children, saving 15.6% of bed days used.

CONCLUSIONS

Medical professionals and parents differ in their views about admission for acute illnesses. More information is needed on children not admitted. Alternative services should take account of patterns of illness and should be acceptable to parents and professionals; cost savings may be marginal.

Planning for the future: the experience of implementing a children's day assessment unit in a district general hospital

A paediatric day assessment unit was opened in May 1995. An audit of the first year's activity showed that, despite an increase in emergency admissions of 8.4%, the number of children admitted as an emergency overnight was reduced by 3% in paediatrics and 7.2% in surgery. In the first year, 1731 children were assessed as an emergency of whom 658 did not require admission to the inpatient ward. Midnight occupancy fell 17.7% in paediatrics and 25.4% in surgery. The nurse staffing costs fell over Pounds 32,000 in the first year. No adverse events occurred during the first year of operation; this type of facility could lead to a more efficient use of resources in any children's unit.

Evaluation of a protocol for selective empiric treatment of fever without localising signs

A protocol for management of young febrile children at risk for bacteraemia has been used at Westmead Hospital, a university based hospital in the western Sydney region, since early 1994. Implementation of the protocol was retrospectively evaluated for the 12 month period 1 June 1994 to 31 May 1995, using the emergency department log book as the primary data source. Altogether 498 children, aged from 3 months to 3 years, with a fever > or = 39.5 degrees C were identified over this period, of whom 291 were admitted to hospital because of evidence of sepsis or identified focal infection and 207 children without focal infection were observed in the short stay annexe of the emergency department. Fifty children, considered at high risk of bacteraemia because of a total white cell count > or = 20 x 10(9)/1 received empiric antibiotic treatment with ceftriaxone, of whom 19 subsequently had proved bacteraemia and another 10 had focal infection identified during observation in the short stay annexe. Bacteraemia was due to Streptococcus pneumoniae in 16 cases and Haemophilus influenzae type b in three. No adverse events occurred at follow up. Use of a management protocol and selection on higher white cell count criterion than previously recommended by US centres resulted in restriction of empiric antibiotic treatment to a small proportion of young febrile children presenting to a busy emergency department of whom 38% were bacteraemic.