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RESULTS AND FINAL CONCLUSIONS 7 March 2012 Prof. Sophie Alexander, Luk Cannoodt et Alain De Wever Researchers: MD Cohen L, Laokri S, Seurynck N, MD PhD Zhang W-H Trybou J, Verhaeghe N BePASSTA Belgian PAediatric Short STAy study 1 Slide 2 G ENERAL CONTEXT 2 The hospitalized child has specific needs (Leiden 1988) At least one parent present during the stay Optimal treatment of pain Specific needs (affective, physical and educational) Hospitalization when home treatment is unavailable RD 13th July 2006: Child Care Program Efficiency Quality of care Accessibility Slide 3 G ENERAL CONTEXT 3 Hospitalization patterns change with time SPF/FOD data Between 1999 and 2007 Mean duration of pediatric stay: stable (from 3,7 to 3,6 days) Number of traditional hospitalizations (-3202 stays per year > -11848 days per year) Number of day care hospitalizations (+5359 admissions per year) Role of the pediatric emergency dep. Observation units/ Observation facility Slide 4 G OALS OF B E PASSTA 4 Pediatric emergency department dfinir les paramtres pertinents pour quantifier le financement ainsi que les activits et les caractristiques des patients (ge, pathologie), du personnel intervenant (actes mdicaux et infirmiers, types de prestations), de la prise en charge (traitements, examens complmentaires, types de procdures), ainsi que le suivi (intra- ou extrahospitaliers des patients. Day care hospital valuer les avantages et les limites de la prise en charge des enfants en hospitalisation de jour et en hospitalisation provisoire par rapport aux autres prises en charge tablir des propositions pour un financement correct de la prise en charge en hospitalisation de jour (au sens large) afin de formuler des recommandations sur la base de ces lments. Slide 5 R ESEARCH TOOLS 5 Slide 6 S ELECTION OF THE PILOT HOSPITALS 6 BePASSTA Slide 7 7 W HAT ARE WE LOOKING FOR ? Patients Populations Flows Workload Performers Acts Financial data Consultations Packages Slide 8 8 Patients Workload Financia l data For each pole P RESENTATION METHODOLOGY Slide 9 C OMPARAISON OF THE 3 POLES : P OPULATIONS 9 IQR : Interquartile Range (Q1-Q3) N : Size of the study population Emergenc y Medical DCHSurgical DCH Median age (years) (IQR) 3.3 (1.2 - 9.1) 6.98 (3.2 - 11.96) 4.7 (2.8 - 8) % Girls46.7%46.0%40.0% Mean nr children/family 1.51.71.5 % Parents with disability [CT1b=2] 3.7% (N=1932)5.2% (N=385)2.4% (N=494) Poverty : % with increased reimbursement [CT1c=1] 16.6% (N=1931) 43.9% (N=385) 16.4% (N=494) Slide 10 E MERGENCY AND O BSERVATION F LOW CHART 10 Almost 40% of all children stay longer in the hospital than a regular consultation Slide 11 DO THEY HAVE A PRIVATE PRACTITIONER? 11 Yes 87,6% Distribution of patients with and without a private practitioner A majority of patients (87,6%) has a private practitioner Slide 12 HOW DO THEY DECIDED TO COME? 12 A majority of patients come spontaneously and have no prior contact with their private practitioner Slide 13 WHY DID THEY COME? 13 For a majority of parents (56,9%), their childs condition is a moderate emergency or no emergency at all Condition felt by parentsN% Extreme/vital emergency2507,9% Moderate emergency143545,5% Situation cant wait until tomorrow104533,2% No doctor can see me now39012,4% The child needs specialized cares103832,9% No real emergency, but I always go to the hospital35811,4% Other (referred by the police, the private practitioner)20,1% Dont know682,2% Total3151100,0% Slide 14 WHEN DID THEY COME? 14 Source: BePASSTA Source: UNMS Almost 40 to 50% of children seen during difficult hours Slide 15 WHAT DOCTOR WAS IN CHARGE? 15 The pediatrician has a pivotal role in the emergency department N% Pediatrician (or assistant) only 192559,8% Emergency doctor (or assistant) but not a pediatrician 64219,9% Multidisciplinary work-up without a pediatrician 44513,8% Multidisciplinary work-up with a pediatrician 2086,5% Total3220100,0% Slide 16 DO ALL THE EMERGENCY CONSULTATIONS NEED THE HOSPITAL? 16 An emergency consultation is called appropriate if it mandatorily needs hospital-specific cares or technics The selection (appropriate/inappropriate) is based on literature-extracted criteria with an a posteriori use and an epidemiological interest only. Slide 17 DO ALL THE EMERGENCY CONSULTATIONS NEED THE HOSPITAL? 17 Criteria for appropriate emergencies Child sent by a doctor Child is come with an ambulance Child is brought by the police After the visit, the child is observed or directly hospitalized Child dies in the hospital after the emergency consultation Cast needed Slide 18 DO ALL THE EMERGENCY CONSULTATIONS NEED THE HOSPITAL? 18 Appropriate contacts 60.7% Inappropriate contacts 39.3% Almost 40% of all the emergency consultations do not require the hospital infrastructures Slide 19 19 APPROPRIATE AND INAPPROPRIATE EMERGENCY CONSULTATIONS A MULTIVARIATE ANALYSIS Parents evaluation Living in Flanders age < 2 years Night / WE / holydays Short distance home-hospital Having a family practitioner Slide 20 WHERE ARE THE CHILDREN OBSERVED? 20 The observed children remain in the Emergency department, mostly not in a bed Slide 21 WHY ARE THE CHILDREN OBSERVED? 21 69% of all children who stay longer in the hospital than a regular consultation, are waiting for results Slide 22 DISTINGUISHING BETWEEN LENGTHY CONSULTATIONS AND REAL OBSERVATIONS 22 Are all observations justified? Probably yes (suggested by doctor and approved by parents) How to distinguish between lengthy consultations and real observations? Criteria for a real observation The child lays in a bed HR, RR, T are regularly checked Duration criterion? Slide 23 E MERGENCY AND O BSERVATION C RITERIA VS. NON CRITERIA OBSERVATIONS 23 10% of all observations meet the criteria Observation typeN% Non criteria observations111490% Criteria observations12310% Total1237100% Slide 24 ARE THE OBSERVATIONS USEFUL? 24 Observations help clarifying an unclear diagnosis, testing a treatment and preventing some hospitalizations Diagnosis unclear 84,3% clarification Test the treatment 88,3% clarification True observations Prevents unnecessary hospitalizations Slide 25 DISCUSSION 25 87,6% of all children have a private practitioner come spontaneously to the emergency department without a prior contact with their doctor What does it mean about the first line pediatric cares? 66,3% of all children see a pediatrician in the emergency department. What exactly is the role of the pediatrician in this department? Slide 26 26 39,3% of the visits to the emergency department do not require hospital-specific cares or technics It is what we have called inappropriate emergency consultation. What should we do about that? 38,6% of all children stay longer than a usual consultation (i.e. observation), which seem to be useful. Should we develop the observation and how? DISCUSSION Slide 27 E MERGENCY AND O BSERVATION THE INTERESTING POPULATIONS 27 General population Observations Criteria- observations Lengthy consultations Non observations Appropriate contacts Inappropriat e contacts Slide 28 E MERGENCY AND O BSERVATION G ENERAL POPULATION : FINANCIAL DATA 28 donebilled Over -billing Under -billing Bill shifting Slide 29 OBSERVATION VS. NON OBSERVATION: WORKLOAD 29 ObservationNon Observation SD O SD NO Test t Nurse 72.32 48.953.48 50.0p