The emergency department (ED) serves as the gateway to hospital admission for the majority of children who require hospitalization in the U.S. However, one in four children with unplanned hospitalizations is admitted directly to an inpatient bed without first receiving care in the hospital’s ED. This process is called direct admission.
When direct admission processes go well, patients and families highly value this admission approach, as it allows them to bypass the often-chaotic ED and settle into the hospital room more quickly. Additional potential benefits of direct admission include improved continuity of care between community-based and hospital-based clinicians, as direct admission involves direct communication between the referring and accepting health care teams. However, clinicians may worry that direct admission could result in delays in care, perhaps resulting in deterioration of a child’s clinical status.
Recognizing that direct admissions are common, experienced by about 400,000 U.S. children each year, the AAP has published recommendations to optimize the quality and safety of this admission approach.
The policy statement, Direct Admission to Hospital for Children in the United States, from the Committee on Hospital Care, is available at https://doi.org/10.1542/peds.2022-060973 and will be published in the March issue of Pediatrics.
The statement provides guidance related to:
- the importance of establishing direct admission written guidelines,
- systems of communication between clinicians and families,
- triage systems to identify patient acuity and disease severity,
- hospital resources to support direct admission systems of care, and
- approaches to evaluate direct admission processes and outcomes at the hospital level.
The policy builds on a systematic review of published studies that have compared the effectiveness of direct admission to admission through EDs, as well as the input and perspectives of family partners, community pediatricians, pediatric hospitalists and other pediatric subspecialists. Recommendations speak to the importance of communication between referring and accepting clinicians, shared documentation to minimize duplicative labs and X-rays, and taking into account local resources when deciding on the appropriateness of direct admission.
Hospital admission processes present valuable opportunities for quality and safety efforts, as these processes of care are experienced by every hospitalized child.
While hospital discharge processes have been the focus of substantial research, health policy and quality improvement efforts, hospital admission processes have received considerably less attention.
The policy’s recommendations are intended to support the implementation of safe direct admission processes by hospitals and health care teams, providing a foundation from which hospitals may develop their own guidelines and quality improvement efforts.
Dr. Leyenaar is a lead author of the policy statement. She is associate editor of the Journal of Hospital Medicine.
