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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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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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

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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

• maces@ccf.org

• Office (216) 445-4598