Comparative Effectiveness of Direct Admission & Admission Through Emergency Departments for Children

Dartmouth Health

Status: Completed

Conditions: Child Health; Hospitalization

Treatments: Behavioral: Direct admission; Behavioral: ED admission

Study type: Interventional

Funder types: Other

Identifiers

NCT04192799

IHS-2018C2-12902-IC

Details and patient eligibility

About

At a national level, emergency departments (EDs) serve as the portal of hospital admission for 75% of hospitalized children. The remainder occur via direct admission, defined as admission to hospital without first receiving care in the hospital's ED. The overall goals of this research are to: (i) implement pediatric direct admission systems at 3 hospitals, (ii) compare the timeliness of healthcare delivery for children who are admitted directly and through emergency departments, (iii) determine which patient populations achieve the greatest benefits from direct admission, and (iv) identify barriers and facilitators of successful implementation.

Full description

The Specific Aims of this research are to: (i) Determine the effect of a pediatric direct admission system on timeliness of healthcare provision (the investigator's primary outcome), family experience of care, and rates of clinical deterioration compared to hospital admission beginning in the ED; (ii) Identify the pediatric populations and conditions that experience the greatest benefits from direct admission; and (iii) Through interviews with key informants, identify barriers to and facilitators of implementing standardized direct admission processes.

To achieve these Aims, a stepped-wedge cluster randomized controlled trial at three geographically diverse hospitals in the United States will be conducted, randomizing primary and urgent care practices in the hospitals' catchment area to cross over to the direct admission intervention at four time points. Linear models with random effects for clusters and time period fixed effects will be used to evaluate outcomes associated with the direct admission intervention. To examine for heterogeneity of treatment effects, interactions between direct admission and a priori-specified subgroups will be examined.

Enrollment: 1,997 patients

Sex: All

Ages: 30 days to 17 years old

Volunteers: No Healthy Volunteers

Inclusion and exclusion criteria

Inclusion Criteria

Child has one of the following presenting diagnoses:

• gastroenteritis
• dehydration
• skin and soft tissue infection
• urinary tract infection/pyelonephritis
• pneumonia
• viral infection not otherwise specified
• influenza

Exclusion Criteria

Ineligible children include those:

• with planned admissions (i.e., chemotherapy)
• admitted to non-pediatric hospital medicine services (i.e., intensive care)
• transferred from other hospitals

Trial design

Primary purpose: Health Services Research

Allocation: Randomized

Interventional model: Crossover Assignment

Masking: None (Open label)

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1,997 participants in 2 patient groups

Direct Admission

Experimental group

Description:

Referring providers contact the hospital to arrange for a child to be admitted directly into the pediatric hospital medicine unit.

Treatment:

Behavioral: Direct admission

ED Admission

Active Comparator group

Description:

Children initially present at the Emergency Department and are then admitted to the pediatric hospital medicine unit.

Treatment:

Behavioral: ED admission