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9/11/2017
1
Special Populations
Pediatrics and the Elderly
Sharon E. Mace, MD, FACEP, FAAP
Professor of Medicine Lerner College of Medicine
at Case Western Reserve University
Cleveland Clinic
Cleveland, Ohio
“Observation Medicine
Principles and Protocols"
• Cambridge
Medical
Publishers
• Apr 2017
• Research
• No COE
Objectives - Special
Populations
• Overview: importance, the why
• Geriatrics: complexity
• Pediatric: “previously well” with acute
illness, CSHCN: children with special health
care needs
• Pediatrics: Is it serious or not?
• Simple Obs: 1 diagnosis, 1 problem vs.
• Complex or extended observation
• Expand observation: include all age groups
• Can it be done ? Yes, anywhere, any setting
Special Populations
Pediatrics and the Elderly
• Currently, elderly 12%, pediatrics 23%
• Combined > 1/3 (35%) of US population
• By 2030, elderly 20%, combined = 43%
• ED visits IOM report: pediatrics 27% +
geriatrics 15% = 42%
• ED visits near future: geriatrics ↑ from
15% to 25%, combined 27%+25% = 52%
• Rate of increase in ED visits is greatest
for elderly
Geriatric ED Patients
• More complex
• Requires more ED resources
• Have longer ED length of stay (LOS)
• Many of conditions managed in OU are
more common in elderly
• Chest pain, syncope, CHF, TIA, COPD
VTE, atrial fibrillation
• “Simple” 1 diagnosis, 1 problem vs.
multiple diagnoses/problems obs
• “Complex/extended”obs < 48 vs < 24 hr
Geriatric vs Nongeriatric
EDOU Patients
• Chest pain #1 diagnosis for both
• OU admit rate: G 26.1%, NG 18.5%
• 30 day return rate: G 9.4%, NG 7.6%
• LOS: G 15.8, NG 14.5 hr
• National LOS mean 15.3, median 19.5
hour
• US study, older data (2003)
• OU LOS decreasing over past decade
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2
Geriatric vs Nongeriatric
EDOU Patients: Coronary Artery
Disease (CAD)
• CAD: previous MI, stent, or bypass graft
• Admit rate: G 31.3%, NG 20.8%, p =.013
• Geriatric: significantly higher % chronic
conditions (risk factors for CAD)
• Hypertension, diabetes, renal disease,
pre-existing heart disease
• Independent predictors of inpatient
admission: history of CAD, renal
dysfunction
Short Stay Unit - Wales
No Geriatric Inpatient Beds
• Age > 70 years, N = 100
• Admit rate 28%
• Likely, actual lower admit rate for OU
patients since inpatient admits not
separated out from OU patients
• US national admit rate 20%
• Benchmark: 80% discharge, 20% admit
EDOU Geriatric Patients
Diagnosis – United Kingdom
• Falls/injuries 45%
• Infections 11%
• Constipation 5%
• Stroke/TIA 3%
• Social 2%
• Others 34%
• Admit rate 29%
• Discharge 71%, usually < 24 hours
Is Age a Predictor of Inpatient
Admit from OU?
• Hypothesis: higher admit rate from OU if
geriatric vs nongeriatric
• Hypothesis: higher admit rate from OU if
multiple comorbidities or problems
• Studies looking at just age: mixed
results
• What are predictors of inpatient
admission from OU?
Non Predictors of Admission
from OU in Geriatric Patients
• Comorbidities: number, Charleston index
• Medications: anticoagulant use,
antiplatelet use, number of meds
• Age, race, obesity (BMI)
• Diagnosis: medical vs surgical
• Marital status
• Insurance
• Smoking
• Alcohol use
Predictors of Admission from
OU in Geriatric Patients
• Fraility, sociodemographic
• Katz index of independence in daily
living
• Lower education
• Illicit drug use
• Some lab: leukocytosis, hypercalcemia
(none were cancer patients)
• Nonpredictors: hgb, sodium, creatinine
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Falls with Subsequent Injury
• Difficulty with mobility - from pain,
underlying precipitating cause dizzy, etc.
• All older patients considered for ED
discharge should be observed arising and
ambulating unless contraindicated (hip fx)
• 74 yo F, fall, hip pain, plain Xray: no fx, OU
• Analgesia: IV opioids initially, switch to po
• Additional resources: SW consult, PT
assessment & training, ambulatory
assistance: walker, home health arranged
Falls with Subsequent Injury
OU Exclusions
• Preexisting impaired mobility:
already walker dependent
• Limited home assistance: lives alone
& no home health care
• Persistent severe uncontrolled pain
after ED pain management
• OU interventions: MRI, analgesia (IV
to po), SW, PT, arrange home health
care, geriatric consult, f/u
Falls with Subsequent Injury
OU management
• Treat underlying cause
• Orthostatic: IVF, adjust meds: low HR/BP if
overmedicated hold meds
• MRI: if missed fractyure, risk for fracture
displacement, avascular necrosis
• Reassess gait prior to OU discharge
• If MRI negative, pain treated, re-ambulate
• Able to ambulate? Yes, d/c or No, admit
Altered Mental Status
Mild Delirium
• Identify, confirm the cause
• Initiate treatment
• Potentially correctable causes during
brief OU stay: 1 (or 2) simple etiology
• Drug side effect (new med, med
interactions), dehydration, drug/alcohol
intoxication/OD, uncomplicated
infection (UTI, cellulitis, pneumonia)
Altered Mental Status
Mild Delirium
• Causes: fever ± UTI ± dehydration ±
mild AKI ± mild electrolyte abnormality
• Bradycardia, low BP, syncope:
overmedicated from ß blocker
• Establish baseline mental status:
call/interview family/friends/caregivers
• Resolution of AMS or delirium or at
baseline → d/c, if not: admit
• CAM = confusion assessment method
Geriatric Abdominal Pain
• Abdominal pain most common ED chief
complaint (all patients)
• Elderly: vague history & exam findings,
“unimpressive” lab results, delayed
presentation, no leukocytosis
• Usually, not chronic abdominal pain
• 1 of 5 elderly, initial ED dx is inaccurate
• 14% elderly discharged from ED
bounceback within 2 weeks
• High volume, high risk, complexity
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4
Geriatric Abdominal Pain
OU Inclusion
• Inclusion: no diagnosis, poor pain
control, unable to take po
• Lack significant history/exam findings
concerning lab (↑ wbc)
• Cholecystitis – often missed
• Stable, US nondiagnostic, suspected,
• Interventions: supportive care
symptomatic treatment, HIDA scan
Geriatric Abdominal Pain
OU Exclusion
• Hemodynamically unstable
• Serious acute metabolic derangements
• Uncontrolled pain after ED treatment
• High suspicion for
- for acute surgical process: exam -
guarding, rigidity
- mesenteric ischemia: nondiagnostic
abdominal CT with elevated lactate
Geriatric Protocol
OU Exclusions• Safety concern/behavioral issues:
severely agitated, combative, SI, HI
• Severe CNS depression: obtunded →
hypoactive delirium
• Severe metabolic abnormalities
• Potentially life threatening withdrawal
syndromes: alcohol, barbiturates,
benzodiazepines
• New focal neurologic deficits
• Suspected CNS infection
Pediatric Observation?
• Is it similar or different from adults?
• Benefits: Why do it? Meet the demand
• Is pediatric observation successful? Yes
• Can it be done? Where?
• Problems or concerns
• Cases in pediatric observation – 2 types
• Previously well, Child with special health
care needs (CSHCN)
What Conditions ?
The Most Common Are
Pediatrics Adults
Asthma Chest pain
Dehydration Heart failure
Gastroenteritis COPD exacerbation /
acute bronchitis
Pneumonia TIA
Abdominal pain Syncope
Seizures Asthma
Fever Abdominal Pain, Dehydration
Bronchiolitis Pneumonia
Croup
Pediatric vs. Adult Observation
• Diagnoses are somewhat different
• Chest pain vs. asthma and dehydration
• Adult OU = cardiac monitoring unit
• Pediatric OU = respiratory unit
• Respiratory = #1, IV hydration is #2
category for pediatrics
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Pediatric vs. Adult Observation
• ↓ need for cardiac monitors in pediatrics
• ↑ need for isolation: diarrhea, respiratory
• ↑ need for respiratory therapy: aerosols
• ↑ need for IV fluids for rehydration
• ↑ incidence: respiratory, infections
• Different supplies, pharmacy stock:
aerosols, anti-emetics, antibiotics:
respiratory,infections (peritonsilar abscess,
cellulitis)
• ↓ Consults, radiology, ancillary tests
Pediatric vs. Adult Observation
• Metrics/Dashboard: LOS, % admits,
complaints, to ICU, to operating room
• Need for CPAP, BiPAP, intubation
• But not rule in or to catheterization
• Personnel: respiratory therapy not
ECGs, phlebotomy
• Equipment/Design/Supplies: ↓ monitors
↑ isolation, ↓ medications
• Use of ancillary services: radiology
studies (MRI, CT), ↓ physical therapy, ↓
consults
Differences Between Pediatric and
Adult Observation
• Seasonal variation in pediatrics
• Based on current infectious disease
• Peaks and valleys vs. straight line
for adults
• Fall / winter- respiratory: croup,
pneumonia, bronchiolitis, late winter -
GI (rotavirus, etc.), summer – trauma
Similarities Between Pediatrics and
Adults in Observation
• Inclusion criteria: stable VS, non-critical
- Do not need intensive nursing care
- Do not need intensive physician care
- Expected disposition in reasonable time frame (<
24 hours)
• Exclusion criteria: unstable VS or critical
- Need intensive nursing
- Need intensive physician care
- Expected disposition > 24 hours
Similarities and Benefits of
Pediatric and Adult Observation
• Benchmark for Obs: 80% discharged, 20% admitted as inpatients but depends on diagnosis, maybe age, and …
• Both use protocols, order sets, care paths
• LOS ≈ 15 hours but depends on diagnosis
• LOS may be less for pediatrics
• Similar benefits: ↓ED LOS, ↓ malpractice, ↓ risk, ↑ patient satisfaction, ↑ Press Ganey, ↓ missed diagnoses, better patient outcome
Pediatric ED Observation vs
Inpatient Admission
• Cost: asthma $5,667. vs. $9,939.
• Cost: dehydration $1,048. vs $8,920.
• LOS s/p BE for intussusception 7.12 vs.
22.7 hr, dehydration (3-24 mo) 9.9 vs. 103.2
• Asthma 72 hr returns to ED 0.6% vs. 2.0%
• Satisfaction: patient 3.49, MD 3.63
1 =lowest, 5 = highest
• Time to phototherapy 1.6 v. 6.7 hr
• No critical incidents, major adverse
events, deaths in any of ped EDOU studies
9/11/2017
6
Pediatric Patients Still
Symptomatic After Initial ED Care
• 16 yo asthmatic still wheezing
• 8 yo peritonsillar abscess, I&D, still in
pain, not taking po
• 5 yo gastroenteritis still vomiting after
po antiemetics
• 3 yo stomatitis, dehydrated
• 2 yo hand cellulitis
• Child with special health care needs
- Fever or not eating or not usual self
- No obvious source or etiology for CC
Pediatric Observation Cases
• 16 yo asthmatic: aerosols, steroids
• 2 yo dehydration: IVF
• 5 yo cellulitis of hand from dog bite
• PMH: negative
• Transfer: time, expense, away from
support systems, parents jobs…
• Option: treat in your EDOU
• Result: next day improved, home on po
• meds
Options
• Uncomfortable in sending home -
Discharge is out
• Admit ped floor: What if no pediatric beds
• Transfer if no pediatric inpatient beds
• Leave in ED for additional time: LOS, TAT
• Place in ED observation unit
• No obs? Why not start one?
• Is your EDOU solely for adults?
• Why not hybrid (both pediatrics, adults) ?
Community Hospital ED
• Hospital does not have pediatric beds
• ED census 35,000
• 5 year old asthma: after ED treatment
• Still wheezing, mild retractions, R 36
• Option: transfer 2 hrs away to Ped ED or
• Place in ED CDU: aerosols, steroids,
• Improves: d/c home on po meds, inhaler
Success in Small Community
Hospital - Pediatrics
• Local pediatricians not available 24
hours/day, joint management with ED
• Concerns
- Training of personnel
- Require at least 1 parent at all times
- Lower age limit: 5 years
• Limit complaints: asthma, dehydration,
UTI, cellulitis, undifferentiated
abdominal pain → Select population
Success in Small Community
Hospital
• Community Hospital: small rural town
• Hospital beds 99, ED census 26,700
• Obs LOS (hours): inpatient 27, ED 15
• 1 year: 848 patients, saved hospital 424
patient days, ↓ED LOS, ↑ED TAT
• Included pediatrics, hybrid unit &
management
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Pediatric ED Observation
• Tertiary PED, 9 common conditions
• Protocols, order sets
• No space or staffing change, type obs?
• 18% obs, admits 25%vs 29% p< 0.02
• Median ED obs LOS 8.8 hrs
• ED LOS admitted patients 6 vs 5.8 NS
• ED LOS discharged patients:
5.6 hours vs. 5.1 hours p < 0.001
Observation Medicine
• What is your hospital type: academic,
community, free standing?
• What is your hospital locale: urban,
suburban, rural?
• Are you doing observation, geriatric
and pediatric observation?
• If no, why not?
• You can geriatric and pediatric
observation successfully anywhere
References• Mace “Care of Special Populations in an
Observation Unit: Pediatrics and Geriatrics”
EM Clin N Am 8/2017
• Hustey “Geriatric Observation Medicine” ch
55
• Mace “Pediatric Observation Medicine” ch 53
• Ojo “Pediatric Observation at a Children’s
Hospital” ch 54
• Puetz ch 16 Gilmore, Nicks ch 17 “Extended
& Complex Obs”
• Prudoff & Sayles “Community Hospital
Perspective in a Suburban/Rural Setting”
ch 10
Contact Info
• Office (216) 445-4598