Table 4.

Benefits, risks and challenges of direct admission, presented thematically with representative quotations and thematic frequencies.

PERCEIVED BENEFITS (n=number of respondents discussing theme)

Theme 1: Patient, family and physician satisfaction (n=78, 76%)

Families are generally more satisfied with direct admissions. It has a VIP feel and they are taken to a room faster. Admissions from the ED unfortunately wait a fair bit of time to get to the inpatient bed…and that is after having waited to be seen in the ED, wait for results, and then wait for a bed. Anyone that has been a direct admit in the past wants to be directly admitted again! PCPs are more likely to send their patients to our hospital because we allow direct admits and our competitors do not.

Theme 2: Improved efficiency of the admission process (n=74, 72%)

Avoidance of the ED for patients and families is the greatest benefit---lower costs, quicker movement to the inpatient service which is more comfortable, avoidance of long ED waits, fewer providers involved such that there is less chance for communication errors and inconsistencies; fewer history and physical exams done on any single, usually tired, patient… From a PCP perspective, if they see a patient in the office and believe they need admission, they usually don't want the patient to incur additional expense or an exam by a non-pediatric ED person. Patients are not stuck in the ED (which is not a peds ED) for hours when we know they are going to be admitted. This is not family-centered. If we can avoid the cost, and inconvenience of the ED for patients that definitely need to be admitted then we try to do that.

Theme 3: Earlier access to pediatric-specific care (n=14, 14%)

Our ED has great staff in general but it is not a pediatric environment and is one more stop or delay for a sick child and their anxious family. …Up-to-date pediatric care (our ER docs do a great job, but they are not pediatric specific ER docs, so do not know a lot of the newest guidelines).

Theme 4: Continuity of care (n=12, 12%)

Direct admits all go through a transfer center, and an accepting hospitalist always has a conversation with a referring provider, so there is a communication mechanism in place to 'reality check' that a direct admit is appropriate. Their caregiver has directly spoken to their new caregiver and they have a sense of security and continuity with that…

Theme 5: Reduced risk of nosocomial infection (n=5, 5%)

Newborn babies are not exposed to the illnesses in the ED waiting room. Immunocompromised hosts [are] at risk for greater exposure to infectious disease in the ED.

PERCEIVED RISKS AND CHALLENGES

Theme 1: Difficulties determining direct admission appropriateness (n=53, 51%)

There is risk with everything we do! The risk of direct admissions is that the child arrives on the inpatient ward unit sicker than billed, or much healthier than represented on the phone and doesn't need to be admitted at all. These do not trump (in my opinion) the huge risk of ballooning costs and getting lots of unnecessary care in an ED prior to getting to our service. We never know if the patient is actually as being described. There are a significant number of admits where they are described as ‘fine’ then arrive needing the ICU or significant resuscitation, or the opposite where a patient is billed as very sick and actually doesn't need admission.

Theme 2: Inconsistent direct admission processes (n=51, 50%)

The process needs to be standardized. We currently have an open policy re: direct admissions and utilize them based upon our judgment. It would be useful to have a policy regarding suitable and unsuitable candidates for direct admission. We often lack in depth information regarding ED or inpatient transfers. We also sometimes are unable to get sufficient information to clarify if the patient is safe to come directly to the floor or needs to go to ED. A consistent triage assessment component is missing, since patients may come from a private office, subspeciality clinic or in-hospital general pediatric clinic. It would help not to have to make 5 phone calls for each admission from another ER: I have to call the charge nurse, patient utilization nurse, sometimes bed control, the residents, and of course the referring ER physician. This takes a lot of time!

Theme 3: Hospital staff workflow/provision of timely care (n=41, 40%)

Nursing staff can be easily overwhelmed by direct admits that require more of their time – blood work, IVs, etc – than the patient that comes through the ED “packaged”. There used to be a big problem with “stealth” admissions, where (often a specialist) would arrange an admission but not communicate to the inpatient attending or residents so a family would show up at a room and the medical team didn't know they were coming. If patients require urgent evaluation this does not happen as well when patients are directly admitted – blood work, radiology, consultation often takes longer on the floor than in the ED.

Theme 4: Concerns for patient safety (n=37, 36%)

During periods of high workload, it may be difficult for a hospitalist to arrive shortly after the directly admitted patient does. In those instances, greater reliance must be placed in the description of the referring physician and upon the floor nursing staff. There is, in these instances, increased risk that something may be missed. I think from a safety point of view, peds ER assessment prior to coming up to floor is the only guarantee that unstable patients not get to floor where care could be suboptimal.