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

Study Overview
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Brief Summary
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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
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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.

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

Conditions
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Hospitalization, Child Health

Intervention / Treatment
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* Behavioral: Direct admission
* Behavioral: ED admission


Participation Criteria
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Eligibility Criteria
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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

Ages Eligible for Study
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Minimum Age: 30 Days
Maximum Age: 17 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Crossover Assignment
Interventional Model Description: stepped-wedge cluster randomized controlled trial
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Direct Admission<br>Referring providers contact the hospital to arrange for a child to be admitted directly into the pediatric hospital medicine unit. | Behavioral: Direct admission<br>* Process of pediatric admission is through admission directly into the pediatric hospital medicine unit<br>|
| Active Comparator: ED Admission<br>Children initially present at the Emergency Department and are then admitted to the pediatric hospital medicine unit. | Behavioral: ED admission<br>* Process of pediatric admission is through the emergency department<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Timeliness of clinical care | Length of time from arrival at the hospital until initiation of definitive clinical care. | within 6 hours of hospital admission | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Rate of clinical deterioration | Transfer for pediatric intensive care, rapid response calls | within 6 hours of hospital admission | 
| High turnover hospitalization | Total length of stay in the hospital of less than 12 and/or 24 hours | within 24 hours of hospital admission | 
| Family hospital admission experience | 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 | Within 72 hours of hospital admission |