Special Populations Pediatrics and the Elderly. Special Populations Pediatrics and the Elderly. Geriatric vs Nongeriatric EDOU Patients

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1 Observation Medicine Principles and Protocols" 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 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 1

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 Is Age a Predictor of Inpatient Admit from OU? Falls/injuries 45% Infections 11% Constipation 5% Stroke/TIA 3% Social 2% Others 34% Admit rate 29% Discharge 71%, usually < 24 hours 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 2

3 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 3

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 4

5 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 hr, dehydration (3-24 mo) 9.9 vs Asthma 72 hr returns to ED 0.6% vs. 2.0% Satisfaction: patient 3.49, MD =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 5

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 6

7 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 < 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)