Problem: In a landmark report, the Institute of Medicine describes our emergency medical system as overburdened, fragmented, and at a breaking point. Over the past two decades, an increasing proportion of children and adults who need hospital admission have been admitted through emergency departments (EDs). In fact, of the 1.5 million unplanned hospitalizations for children that occur each year, 75 percent originate in EDs. The remainder occur via direct admission, defined as admission originating from patients’ homes or health clinics, typically facilitated by direct conversations between community-based and hospital-based healthcare providers.
Unlike healthcare delivery through most of the 20th century, hospitalists (physicians specializing in hospital-based care) provide a large proportion of hospital-based care at many hospitals, with relatively few primary care physicians providing hospital-based care. As a result, hospitals need direct admissions systems to receive referrals from community-based physicians. Without such direct admission systems, the majority of hospital admissions will begin in EDs. Although patients, their caregivers, and their healthcare teams all describe potential benefits of direct admission, including elimination of ED waiting times and reduced ED crowding, very few studies have compared the risks and benefits of these hospital admission approaches. Studies in children are particularly lacking.
Approach and Outcomes: The overall goals of this research are to implement pediatric direct admission systems at 3 hospitals, compare the timeliness of healthcare delivery for children who are admitted directly and through EDs, determine which patient populations achieve the greatest benefits from direct admission, and identify barriers and facilitators of successful implementation. In addition, we will examine parent-reported experience of care, emergency response calls, and rates of unplanned transfer to the intensive care unit. We will evaluate these outcomes using a cluster randomized controlled study design at 3 hospitals, in which we randomize 47 pediatric primary care practices to participate in the direct admission intervention at 3 different time points and examine outcomes in more than 1,200 children and adolescents.
Patient and Stakeholder Partnership: The direct admission intervention that will be implemented in this study was developed through a process of multi-stakeholder engagement, including nurses, parents, physicians, payers, and others. Similarly, its implementation at our three partnering hospitals will require active engagement of community-based healthcare providers, hospital-based healthcare teams, and families. We have therefore brought together a team of pediatric hospitalists, pediatric primary care providers, and parent partners to implement the direct admission intervention, supported by a team of researchers with expertise in pediatrics, statistics, and implementation science. In addition, multi-stakeholder Direct Admission Leadership Teams at each hospital and a national Direct Admission Advisory Board will support implementation and evaluation. To identify barriers and facilitators of implementing standardized direct admission processes, analysis will be conducted in partnership with an experienced parent partner, with a goal of generating knowledge to inform direct admission implementation beyond our study sites.
*All proposed projects, including requested budgets and project periods, are approved subject to a programmatic and budget review by PCORI staff and the negotiation of a formal award contract.
^This project was originally affiliated with the Trustees of Dartmouth College.