Infants and children and the elderly comprise a large and growing (especially the elderly) segment of the US population. The benefits of observation medicine have been documented in these two age groups: Based on the success of observation medicine, and recognizing the growth of these special populations, it is likely that observation medicine will be expanding in the future, especially within the pediatric and geriatric populations. Future studies should be able to provide further evidence regarding the value of observation medicine in these two diverse population age groups.
Key points
- •
Special populations, such as pediatrics and the elderly, are a large and growing segment of the observation population.
- •
Special populations are complex, high-risk, vulnerable patients who present unique challenges and can be difficult to assess during a brief emergency department (ED) visit.
- •
An observation unit stay allows time to arrive at a diagnosis, evaluate, and/or treat these complex patients.
- •
Patients of all ages from newborns to the elderly with a wide variety of diagnoses can be safely and effectively treated in an ED observation unit.
- •
Benefits of observation unit care include better or equivalent patient outcomes, decreased cost, decreased lengths of stay, improved ED efficiency, and avoidance of unnecessary inpatient admissions with potential for iatrogenic complications.
Overview: pediatric and geriatric demographic trends and emergency department use
Children and infants comprise about one-fourth of the population of the United States; 23% are less than 15 year old. The elderly (≥65 year old) make up 12% and are the fastest growing segment of the population. By the year 2030, it is estimated that the proportion of the population that is elderly will increase to 20%. These 2 population groups, pediatrics and geriatrics, currently comprise over one-third (37%) of the population and by 2030 will account for almost half (45%).
According to an Institute of Medicine report, over 40% of emergency department (ED) visits are for a pediatric (27%) or geriatric (15%) patients. The rate of increase in ED visits is greatest for the elderly population. Within the next 2 decades, the proportion of ED visits by geriatric patients is anticipated to increase to 25%.
Sydney White is a 4-year-old girl with a history of asthma brought to the ED by her mother with increased respiratory distress and audible wheezing that started overnight. In the ED, she is febrile to 101.7°F; her pulse oximetry is 94% on room air. Respiratory rate is 45 breaths per minute, and heart rate is 140. She has a clear chest radiograph and tests positive for influenza A. Despite oseltamivir, ibuprofen, acetaminophen, nebulizer therapy, and oral corticosteroids, she shows only mild improvement and still has significant wheezing on pulmonary examination with low-grade fever. She is placed in the ED observation unit (EDOU), where she receives nebulized bronchodilator therapy every 3 hours, around-the-clock antipyretics, intravenous (IV) hydration, and serial examinations. Re-evaluation the next morning shows her work of breathing has significantly improved. She is discharged 17 hours after ED presentation with prescriptions for a short-term course of oral corticosteroids, a course of oseltamivir, and follow-up with her pediatrician the next day.
Overview: pediatric and geriatric demographic trends and emergency department use
Children and infants comprise about one-fourth of the population of the United States; 23% are less than 15 year old. The elderly (≥65 year old) make up 12% and are the fastest growing segment of the population. By the year 2030, it is estimated that the proportion of the population that is elderly will increase to 20%. These 2 population groups, pediatrics and geriatrics, currently comprise over one-third (37%) of the population and by 2030 will account for almost half (45%).
According to an Institute of Medicine report, over 40% of emergency department (ED) visits are for a pediatric (27%) or geriatric (15%) patients. The rate of increase in ED visits is greatest for the elderly population. Within the next 2 decades, the proportion of ED visits by geriatric patients is anticipated to increase to 25%.
Sydney White is a 4-year-old girl with a history of asthma brought to the ED by her mother with increased respiratory distress and audible wheezing that started overnight. In the ED, she is febrile to 101.7°F; her pulse oximetry is 94% on room air. Respiratory rate is 45 breaths per minute, and heart rate is 140. She has a clear chest radiograph and tests positive for influenza A. Despite oseltamivir, ibuprofen, acetaminophen, nebulizer therapy, and oral corticosteroids, she shows only mild improvement and still has significant wheezing on pulmonary examination with low-grade fever. She is placed in the ED observation unit (EDOU), where she receives nebulized bronchodilator therapy every 3 hours, around-the-clock antipyretics, intravenous (IV) hydration, and serial examinations. Re-evaluation the next morning shows her work of breathing has significantly improved. She is discharged 17 hours after ED presentation with prescriptions for a short-term course of oral corticosteroids, a course of oseltamivir, and follow-up with her pediatrician the next day.
Introduction: pediatrics
Infants and children are a higher-risk, more vulnerable, and more complex patient population compared with adults. They can be challenging to assess, make a definitive diagnosis in, and institute appropriate treatment for. Obtaining a history can be difficult, especially in preverbal infants/children because of limited ability to communicate symptoms and express experience of pain. Nonspecific complaints such as not eating, fever, vomiting, and caregiver concerns that “they are just not their usual self” are common. Physical examination may have subtle or limited findings. Children and adolescents may be reluctant to provide an accurate history for fear of punishment. Depending on their developmental stage and/or behavioral issues, the pediatric patient may not always be cooperative ( Box 1 ). Physiologic and anatomic differences place the pediatric patient at greater risk. These patients have less physiologic reserve, greater susceptibility to infection, less developed organ systems (eg, liver, kidneys, and central nervous system), greater susceptibility to traumatic injury (eg, proportionally greater head size to rest of body, smaller size, weight, height, muscle mass, fat, subcutaneous tissue), greater reliance on heart rate rather than stroke volume to maintain cardiac output, and higher baseline respiratory rate, heart rate, oxygen consumption, and metabolic rate (see Box 1 ).
History and social factors
- •
Frequently present with nonspecific complaints
- •
Inability or limited ability to communicate (preverbal children and infants: inability to rely symptoms or pain, or give any history)
- •
Limited mobility
- •
Limited cognition
- •
Caregiver dependence
- •
Developmental stages: affects motor and verbal skills, psychological development and behavior
- •
Concern for radiation exposure (increased lifetime risk of malignancy)
- •
Behavioral or mental health issues: autistic, attention deficit hyperactivity syndrome, drug use
- •
Special health care needs or those with disabilities
Physiology and anatomy
- •
Subtle physical examination findings
- •
Increased susceptibility to infection
- •
Limited physiologic reserve
- •
Smaller total blood volume, same amount of blood loss may cause shock in a child or infant but not in an adult
- •
Airway: smaller diameter, larynx more anterior and cephalad; cricoid cartilage is narrowest part of airway, smaller lung volumes
- •
Immature kidneys: lesser ability to concentrate urine and purify toxins
- •
Immature liver: lesser ability to handle toxins
- •
Immature central nervous system: for example, not fully myelinated until 2 years of age
- •
Increased body surface area relative to weight, leads to a predisposition to dehydration and hypothermia
- •
Lesser total muscle mass
- •
Lesser total amount of body fat
- •
Thinner skin: affects absorption of drugs and toxins via the dermal route
- •
Smaller size including smaller stature or height
- •
Lesser weight
- •
Proportionately larger head to body ratio, leads to increased susceptibility to head trauma
- •
Increased susceptibility to general trauma compared with an adult: less protective fat, subcutaneous tissue, muscle to cushion internal organs from trauma and more likely to be thrown further since smaller size and weight, different types of traumatic injuries
- •
Increased heart rate in infants and young children compared with adults
- •
Greater reliance on increase in heart rate rather than stroke volume to maintain cardiac output
- •
Increased respiratory rate in infants and young children compared with adults
- •
Increased metabolic rate
- •
Increased oxygen consumption
Most children and infants seen in the ED will have only a mild illness or injury. Differentiating serious limb- or life-threatening illness/injury from a benign condition can be difficult and sometimes impossible in a brief ED encounter. Fever can be due to a viral upper respiratory infection (URI), bacteremia, meningitis, or sepsis. Abdominal pain can be present in gastroenteritis or appendicitis. Vomiting may be the only symptom of gastroenteritis, but, it may also be seen in diabetic ketoacidosis (DKA), central nervous system disease, and in surgical conditions of the abdomen (eg, intussusception, malrotation). There are nearly 15 million children with special health care needs (CSHCN) in the United States. This comprises nearly one-fifth (19.8%) of all children nationally from birth to 17 years of age. Caring for CSHCN who have multiple medical problems adds another layer of complexity that requires significant time and/or resources to assess, diagnose, and initiate treatment in. Nonaccidental trauma should be considered in any pediatric complaint. Malpractice claims attest to the complexity of evaluating pediatric patients in the ED. Meningitis, followed by appendicitis, is the most frequent diagnosis in pediatric malpractice claims.
The use of EDOUs allows time for more extended evaluation beyond the initial ED visit alone to determine which illnesses/injuries are more serious and may require inpatient admission. Another benefit of observation is the ability to perform serial examinations and avoid use of computed tomography (CT) scanning for conditions such as minor head trauma and abdominal pain.
Walter Jenkins is an 84-year-old man with a history of diabetes, chronic obstructive pulmonary disease (COPD) and mild dementia who lives with his wife and presents via ambulance to the ED after a fall from standing. Further history from the patient and his wife reveal several weeks of generalized weakness and 2 other falls during the period. In the ED, his trauma evaluation is reassuring, and laboratory analysis reveals serum glucose of 288 mg/dL, serum sodium level of 128 mEq/L, and pyuria. He also appears unsteady on his feet and mildly dehydrated on examination, but vital signs are normal. He is placed in the EDOU, where he receives an initial dose of intravenous antibiotics and hydration as well as endocrine, case management, and physical therapy consultations. The next day, he is transitioned to an oral antibiotic regimen with an improving sodium level and is safely ambulating with the assistance of a new walker. The endocrine team recommends a new diabetes regimen, and case management arranges for a visiting nurse to visit his home the next day. He is discharged home with a follow-up appointment scheduled with his primary care physician within 1 week.
Introduction: geriatrics
Many factors make the elderly a high-risk, complex, and more vulnerable population. These variables may be related to impairment of the senses, physical limitations, impaired cognition, psychosocial issues, and medical conditions ( Box 2 ).
History and social factors
- •
Impaired communication: aphasia (such as s/p stroke), incoherent or and/or disoriented (delirium, dementia)
- •
More complex psycho-social needs
- •
Fall risk: predisposition to falls because of impaired balance, poor vision, decreased muscle strength, limited exercise tolerance, deconditioning
- •
Inability to ambulate or difficulty in walking: need for assistive devices (eg, canes, walkers, wheelchairs), bedridden
- •
Limited cognition: Alzheimer disease, Parkinson disease, dementia, stroke patients
- •
Difficulties with the activities of daily living: bathing, dressing, eating, toileting, transferring, mobility
Physiology and anatomy
- •
Chronic health conditions
- •
Sensory impairment: decreased hearing or deaf, vision impairment or blindness
- •
Medication dependent
- •
Oxygen dependent: COPD, heart failure
- •
Technology dependent: cardiac – pacemaker, AICD, LVAD; respiratory: BiPAP. CPAP, ventilators, suctioning, tracheostomy: renal: dialysis: hemodialysis or peritoneal dialysis
- •
Wound/stoma care
- •
Urologic devices: Foley catheters, suprapubic catheters, nephrostomy tubes
- •
Feeding tubes/Special diets
- •
Monitoring: diabetics – blood sugar, hypertension – check of blood pressure
Many of the elderly have contagious conditions, are chronically ill, or may be in palliative or hospice care. They often need devices for assistance with mobility (eg, canes, walkers, or wheelchairs). Because of impaired mobility, they are at risk for falls, which often necessitate an ED visit. They may need assistance with the activities of daily living (ADLs): bathing, dressing, eating, toileting, transferring, and mobility. Should there be a problem or interference with the ADLs, such as poor oral intake causing dehydration, it often leads to an ED visit and admission. Elderly ED patients are more complex, use more resources, and have longer ED lengths of stay (LOS).
Hospitalization of the geriatric patient frequently leads to iatrogenic complications related to the hospitalization itself: medication errors, acute psychosis, nosocomial infections, venous thromboembolic events, falls, and deconditioning. Thus, avoiding unnecessary hospital admission is a desired outcome. EDOUs serve to provide additional care while preventing these potentially avoidable admissions.
Many of the common conditions evaluated and treated in EDOUs are seen more frequently in the elderly:
Cardiac—chest pain, mild congestive heart failure (CHF), atrial fibrillation
Respiratory—COPD, pneumonia, acute bronchitis
Neurologic—transient ischemic attack (TIA)
Metabolic—diabetes complications, hyperglycemia, hypoglycemia, diabetic ketoacidosis
Infections—cellulitis
Syncope
It has been suggested that many of the common presenting symptoms of the elderly in the ED are well suited to EDOU evaluation and treatment, including falls and injuries, altered mental status, and acute abdominal pain.
The evidence for emergency department observation unit care of geriatric patients
In a US study comparing EDOU nongeriatric with geriatric patients, chest pain was the leading diagnosis for both age groups, although the other diagnoses most frequently seen differed between the groups. Admission rates were significantly higher for geriatric versus nongeriatric patients (26.1% vs 18.5%). Thirty-day return visit rate was higher for geriatric versus nongeriatric patients (9.4% vs 7.6%). LOS was significantly longer for geriatric (15.8 hours, 95% confidence interval [CI] 15.7–16) versus nongeriatric patients (14.5 hours, 95% CI 14.3–14.5), although the geriatric patients’ LOS was similar to those previously reported; EDOU mean LOS was 15.3 hours, and median LOS 19.5 hours.
Another US study evaluated EDOU patients with coronary artery disease (CAD), defined as previous myocardial infarction, presence of coronary stent, or coronary bypass graft. There was a significant difference in the admission rate from the EDOU between geriatric and nongeriatric cohorts (31.3% vs 20.8%, P = .013). Geriatric patients had a significantly higher proportion of chronic conditions that increased risk for acute coronary syndrome: hypertension, diabetes, renal dysfunction and pre-existing heart disease. A history of CAD and renal dysfunction were independent predictors of inpatient admission.
A study conducted in Wales by Harrop and Morgan evaluated 100 geriatric (>70 years) patients in a short-stay unit (SSU) when no geriatric inpatient hospital beds were available. The overall SSU discharge rate of 72% is consistent with typical US EDOU discharge rates of 80%. The discharge rate in the Wales study was likely lower than would be expected, because although some patients met inpatient criteria, they were placed in an EDOU and were not separated out from the other patients for data analysis.
The most common diagnoses of geriatric patients in an EDOU study from the United Kingdom were: falls/injury 45%, infections 11%, constipation 5%, collapse 4%, stroke/TIA 3%, social 2%, and others 30%. By diagnosis, admission rates were: falls/injuries 35%, infections 15%, collapse 6%, constipation 5%, stroke/transient ischemic attack (TIA) 3%, social 2% and others 34%. Overall, 71% of patients were discharged home and were usually discharged within 24 hours.
Advanced Age as a Predictor of Inpatient Admission from the Emergency Department Observation Unit
Increasing age was a predictor of requiring inpatient hospital admission from the EDOU in some studies but not in others. A study of EDOU patients found that frailty and sociodemographic factors and not geriatric age are predictors of inpatient hospital admission. Frailty (measured by the Katz index of independence in daily living), disability insurance, and lower education were predictors of inpatient hospital admission from an EDOU. Age, race, gender, obesity as indicated by weight (body mass index), diagnosis category (surgical or medical), marital status, insurance, medical history (comorbidities [eg, number of, Charleston index], number of medications, anticoagulant use, antiplatelet use), smoking, and alcohol use were not predictors. Illicit drug use within 30 days was a predictor of inpatient admission. Laboratory values that were not predictive of admission were hemoglobin, sodium, and creatinine; leukocytosis and hypercalcemia (although none of the patients included were cancer patients) were predictive.
Pediatric Observation Medicine: Historical Perspective
Pediatric EDs in the 1970s and 1980s often designated a room(s) in the ED, and they were used to treat children/infants of all ages, even very young infants, with all types of diagnoses for a short time period. These forerunners of today’s pediatric EDOUs were termed ED holding room (HR), holding unit (HU) or SSU. They reported the same benefits of pediatric observation that are found today: significantly shorter LOS, lower costs, decreased inpatient admissions, fewer returns to the ED (reoccurrence rates), and high parent satisfaction. The most common diagnoses were similar to types of pediatric patients treated in our EDOUs today: respiratory, gastroenteritis/dehydration, neurologic, trauma, ingestion, and infections.
Related posts:
Care of Metabolic and Endocrine Conditions in the Observation Unit
Care of Neurologic Conditions in an Observation Unit
Care of Respiratory Conditions in an Observation Unit
Care of Metabolic and Endocrine Conditions in the Observation Unit
Care of Neurologic Conditions in an Observation Unit
Care of Respiratory Conditions in an Observation Unit
Full access? Get Clinical Tree
