One in four unscheduled hospital admissions for children and adolescents in the United States occurs via direct admission, defined as hospital admission without first receiving care in the hospital’s emergency department. The purpose of this policy statement is to present recommendations to optimize the quality and safety of this hospital admission approach for children. Recommendations included in this policy statement provide guidance related to: (i) direct admission written guidelines, (ii) clear systems of communication between members of the health care team and with families of children requiring admission, (iii) triage systems to identify patient acuity and disease severity, (iv) identification of hospital resources needed to support direct admission systems of care, (v) consideration of patient populations that may be at increased risk of adverse outcomes during the hospital admission process, (vi) addressing the relevance of local factors and resources, and (vii) ongoing evaluation of direct admission processes and outcomes. The recommendations included in this policy statement are intended to support the implementation of safe direct admission processes and to foster awareness of outcomes associated with this common portal of hospital admission.
Introduction
Each year, approximately 2 million children and adolescents are admitted to hospitals in the United States, with hospital care accounting for more than 40% of all pediatric health care expenditures.1–3 Three-quarters of these hospital admissions are unplanned (ie, nonelective) and are facilitated in 1 of 3 ways: as a transfer from another hospital, as an admission beginning in the emergency department (ED), or as a direct admission, defined as hospital admission without first receiving care at another hospital or in the admitting hospital’s ED. Hospital admission processes present important opportunities for quality and safety efforts, because they are experienced by every hospitalized child across the spectrum of hospital types where children receive their care.
At the time of hospital admission, children and adolescents may experience many of the same processes of care that have been the focus of hospital discharge quality improvement initiatives, including unstructured handoffs and poor communication between health care clinicians. Also similar to hospital discharge, hospital admission may cause substantial stress for patients and their families.4,5 Although hospital discharge processes have been the focus of several quality improvement efforts over the last decade, analogous guidance to improve hospital admission processes is scant, particularly in the case of direct admission. Direct admissions may originate from primary care practices, specialty clinics, urgent care centers, and patients’ homes. Among all pediatric hospitalizations, including scheduled admissions for surgeries, procedures, and chronic disease management, almost half originate as direct admissions. Among unscheduled hospitalizations for children, 25% begin as direct admissions, reflecting almost 400 000 hospital admissions annually.6
Although research suggests diverse benefits of direct admission for children and their families, questions about the safety of this hospital admission approach have also been raised by key stakeholders.7–9 The purpose of this policy statement is to therefore present recommendations to optimize the quality and safety of this hospital admission approach for children. The focus of this policy statement is on nonelective, unscheduled direct admissions to pediatric medical–surgical units. Excluded from this statement are recommendations regarding direct admission for intensive care, given the unique issues associated with ICU admissions facilitated by emergency medical services. Also excluded are recommendations about interhospital transfers, deemed beyond the scope of this policy statement. Furthermore, the majority of recommendations apply to direct admissions in which the referring and accepting health care clinicians differ. Not all of these recommendations will apply to direct admissions performed by ambulatory care physicians who admit their own patients to the hospital.
Background
A systematic review, conducted in 2017, identified 19 studies that reported outcomes associated with direct admission processes of care compared with admission through EDs.6,8,10–26 The vast majority of these studies evaluated outcomes related to the timeliness of clinical care delivery provided to adult patients with signs and symptoms concerning for acute myocardial infarction. Of the 14 studies focused on this population, 13 reported timeliness outcomes, and 12 of the 13 (92%) reported more rapid definitive clinical management in adults who were directly admitted.10–12,14–16,19–26 Almost all of these studies, conducted in diverse settings, including Australia, Canada, France, Germany, Israel, Italy, Sweden, the United Kingdom, and the United States, were cohort studies evaluating purposefully designed programs of prehospital evaluation paired with direct communication with inpatient health care teams before hospital arrival. Although many of these studies may have been underpowered to determine differences in mortality rates between patients admitted directly and via EDs, 2 studies did report reduced mortality among directly admitted patients.23,24 On the basis of this systematic review, the authors hypothesize that purposefully designed direct admission processes may improve timeliness of health care delivery for target populations.
In contrast, two studies of adult populations conducted using administrative data from the United States have raised concerns about increased mortality associated with direct admission to hospital. The first, by Powell and colleagues, found that adults with sepsis experienced higher mortality when admitted directly than when admitted through EDs.17 The second, a study of unscheduled adult hospitalizations for a variety of common conditions, found that patients admitted directly had higher mortality for time-sensitive conditions, such as acute myocardial infarction and sepsis, than patients admitted through EDs. These differences were not observed among adults admitted with other common, yet frequently less emergent, conditions including pneumonia, asthma, and cellulitis.18 Another study of febrile adults with cancer, in which investigators implemented and evaluated a febrile neutropenia pathway quality initiative project in the ED, found that time to antibiotic administration was significantly shorter among adults admitted through the ED during the study period than among adults admitted directly, and that ED admission was also associated with shorter hospital length of stay. Taken together, these studies highlight the importance of timely clinical care delivery for hospitalized patients and potential risks associated with delays in care in the absence of purposefully designed direct admission systems.
The pediatric literature about direct admission to hospital is more limited than that available for adults. In a study using the Kids Inpatient Database, which reflects national patterns of pediatric hospitalizations, Leyenaar et al found that direct admission rates for unscheduled hospital admissions varied considerably across hospitals and conditions, ranging from 8.9% for appendectomy to 38.0% for bipolar disorder. In models adjusting for patient and hospital characteristics and disease severity, they found that direct admissions were associated with 5% to 31% lower costs than admissions originating in the ED.6 Similarly, a retrospective cohort study of children hospitalized with pneumonia found that children admitted directly received fewer diagnostic tests and incurred significantly lower health care costs than children admitted through the ED, with no significant differences in rates of ICU transfer or hospital readmission.8 In this cohort, directly admitted children had marginally longer lengths of stay; children admitted through the ED were significantly more likely to be discharged within 24 hours of hospital admission than children directly admitted to the hospital. In a retrospective cohort study determining the relative risk of preventable unplanned transfers to the ICU among direct- and ED-admitted children, Reese and colleagues found no significant differences between children admitted via these 2 portals of hospital admission.9
Findings from this review are augmented by a survey of pediatric inpatient medical directors, which found that 95% of hospitals accepted pediatric direct admissions, and 50% expressed the view that more children should be admitted directly. Perceived benefits of direct admission for pediatric patients reported in this study included improved efficiency of health care delivery, improved patient experience of care, greater continuity across outpatient and inpatient settings, and reduced risks of health care-associated infection.7 Reported concerns about the safety of direct admission processes included potential delays in initial evaluation and management, inconsistent admission processes, and difficulties determining the appropriateness of patients for direct admission, all of which could adversely impact patient safety and quality of care.
Recommendations
The potential benefits of direct admission to improve the timeliness of health care delivery, reduce health care utilization, and improve continuity of care across outpatient and inpatient settings must be balanced with potential safety concerns. Therefore, the American Academy of Pediatrics Committee on Hospital Care supports the following recommendations, informed by the above-described research and guidelines established by a multidisciplinary panel.27 These recommendations were developed through a process of multistakeholder engagement that included interviews with parents of hospitalized children regarding their hospital admission preferences and experiences,4 deliberative discussions with parents and clinicians about how to optimize direct admission systems of care,27 a Delphi process to establish recommendations and prioritize outcomes,27 and review and input from several American Academy of Pediatrics committees.
1. Written Guidelines
To facilitate consistent systems of care within the inpatient health care team and to establish effective outpatient to inpatient handoffs, it is recommended that hospitals accepting direct admissions develop and share written direct admission guidelines with referring practices and hospitals.
It is recommended that direct admission guideline components include:
Diagnoses/conditions recommended for direct admission (conditions recommended for direct admission may vary across hospitals, but may include failure to thrive, skin and soft tissue infections).
Diagnoses/conditions not recommended for direct admission (conditions not recommended for direct admission may vary across hospitals, but may include trauma, hemoptysis, gastrointestinal bleeding).
Diagnoses/conditions acceptable for direct admission from home (conditions acceptable for admission from home may vary across hospitals, but may include neonatal jaundice, cystic fibrosis exacerbation not responding to outpatient antibiotics).
A description of the accepting hospital’s capacity to perform emergent tests or treatments; it is recommended that, at the majority of hospitals, children appropriate for direct admission have a clinical condition that allows them to safely wait on the hospital unit for an agreed-upon period of time before assessment/management by a member of the hospital team.
Times of day that direct admissions will be accepted; direct admissions may be limited to the period of time that a physician or advanced practice provider is available to see the patient when he or she arrives at the hospital. Hospital personnel credentialed with admitting privileges will vary across health care systems.
2. Communication Systems
Direct admissions are facilitated by direct conversations between referring and accepting health care professionals.
It is recommended that hospitals have established, consistent systems to receive direct admission referrals, to document key information, and to share information with the inpatient health care team. As part of the direct admission referral process, it is recommended that a direct and mutually respectful conversation occur between the referring and accepting clinician, with person(s) joining the call who are aware of current bed and staff availability, as well as wait times for beds (if applicable).
To facilitate effective information exchange and reduce the likelihood of duplicative diagnostic testing, the accepting hospital may consider having a secure fax number or electronic medical record system that allows the referring clinician to share relevant information at the time of the patient referral (for example, clinic notes and diagnostic testing results).
Safe transportation to the hospital is another important component of the direct admission process. It may be in the patient’s best interests for the referring and accepting health care clinicians to discuss appropriate modes of transportation to the hospital. Ambulance services transporting patients for direct admissions may benefit from having a contact number for a health care professional at the accepting hospital; admitting hospitals may benefit from receiving updates if the clinical status of the patient changes en route to the hospital.
3. Appropriate Patient Triage
The safety and quality of pediatric direct admission processes is often contingent on recognition of and communication about the clinical stability of a child.
It is recommended that health care professionals requesting direct admission have details about the child’s current clinical status available at the time of the request for admission, including vital signs and other clinical details. Patients deemed too ill or unstable for hospitals’ direct admission systems may be directed to the ED for initial disease management.
To reduce unnecessary hospitalizations, patients who do not meet hospital admission/observation criteria at the time of the patient referral (on the basis of the accepting physician judgment) may also be directed to the ED for initial assessment and management.
4. Hospital Resources for Patient Care
To evaluate the clinical condition of children being admitted directly to the hospital, it is recommended that a member of the health care team (for example, a nurse, resident, or attending physician) be available to assess the patient's vital signs and clinical status soon after the patient’s arrival at the hospital.
Timely initiation of treatment will also be facilitated by the availability of medications and supplies commonly required for directly admitted patients on the admitting unit of the hospital. Efficient direct admission processes may also be enabled by the availability of appropriate wheelchairs at the planned site of entry into the hospital.
5. Special Populations
Some patients may be at increased risk of adverse outcomes when they are admitted through EDs because of underlying immunosuppression or behavioral disorders.
Whenever possible, it is recommended that a child’s risk from infectious disease exposures in the ED be taken into account when deciding whether that patient can be admitted directly. Special efforts may be warranted to directly admit neonates and children who are immunocompromised, if the infrastructure exists to provide clinical care safely and effectively.
Additional pediatric populations that may be well suited to direct admission include those who are well known to the inpatient care team, including children with chronic illnesses, children experiencing hospital readmissions, and children admitted for end-of-life care.
6. Communication With Families
The safety of the direct admission processes may be optimized by the timely arrival of the child requiring hospital admission.
If the child requiring hospital admission is off-site from the hospital and not arriving by ambulance, timely provision of clinical care may be enhanced if referring clinicians provide specific guidance to families/caregivers to come directly to the hospital without making stops at home or elsewhere, unless otherwise discussed between referring and accepting clinicians.
The provision of clear instructions to families/caregivers about how to get to the pediatric unit where their child will be admitted, whom to meet/ask for, the name of the accepting physician, a contact number at the hospital if they get lost or experience other delays, and what they need to bring to the hospital (for example, any home medications or equipment/supplies) may enhance family experience of care.
To minimize the risk of providing families with mixed messages about the inpatient care plan, it is recommended that referring clinicians explain to families that their child will be evaluated by the hospital-based health care team after they have arrived at the hospital and that their child’s treatment plan will be informed by this evaluation.
7. Relevance of Local Factors
More than two-thirds of pediatric hospital admissions in the United States occur outside of freestanding children’s hospitals.3 Many of these hospitals do not have dedicated pediatric EDs or pediatric emergency medicine clinicians. Direct admission may be particularly advantageous at hospitals that do not have dedicated pediatric emergency medicine services, providing children with earlier access to pediatric-specific care on pediatric units.7 However, this may not be applicable in all hospital settings.
It is recommended that a hospital’s direct admission policies and procedures be informed by local health care system factors, including the availability of pediatric inpatient care clinicians, travel times from the referring health care clinician to the hospital, and the current availability of both inpatient beds, as well as health care team members to provide timely clinical care.
8. Evaluation of Direct Admission Processes and Outcomes
Effective direct admission processes involve a large group of multidisciplinary health care professionals, as well as the child and his or her caregivers.
A multidisciplinary quality review process to review outcomes for directly admitted patients may be beneficial to inform ongoing systems improvements and quality improvement studies. Participants in the multidisciplinary review process may include both referring and accepting health care clinicians, including nurses, advanced practice providers, trainees, and physicians, as well as youth and families. Potential outcomes to evaluate direct admission processes are summarized in Table 1, as previously prioritized by multidisciplinary stakeholders.27
Outcomes to Evaluate the Quality and Safety of Direct Admission to the Hospital
| Timeliness . |
|---|
| • Total time from the time of arrival on the pediatric unit to initial assessment by the admitting physician or advanced practice provider |
| • Time from initial call from the referring clinician until the patient is accepted for direct admission or routed elsewhere |
| • Total time from the time of arrival on the pediatric unit to initiation of treatment |
| Efficiency |
| • Number/% of patients admitted to the unit or service who are admitted directly |
| • Number/% of directly admitted patients who are discharged from the hospital within 8 h of arrival |
| • Number/% of directly admitted patients believed to be unnecessary or inappropriate from the perspective of the accepting physician |
| • Total costs of the hospitalization |
| Safety |
| • Unanticipated transfer to the PICU or to another hospital for a higher level of care within 6 h of hospital admission |
| • Rapid response calls within 6 h of hospital admission |
| • Rates of medication errors |
| Experiences of care |
| • Patient and family experience of care |
| • Referring clinician experience of care |
| • Inpatient team experience of care |
| Timeliness . |
|---|
| • Total time from the time of arrival on the pediatric unit to initial assessment by the admitting physician or advanced practice provider |
| • Time from initial call from the referring clinician until the patient is accepted for direct admission or routed elsewhere |
| • Total time from the time of arrival on the pediatric unit to initiation of treatment |
| Efficiency |
| • Number/% of patients admitted to the unit or service who are admitted directly |
| • Number/% of directly admitted patients who are discharged from the hospital within 8 h of arrival |
| • Number/% of directly admitted patients believed to be unnecessary or inappropriate from the perspective of the accepting physician |
| • Total costs of the hospitalization |
| Safety |
| • Unanticipated transfer to the PICU or to another hospital for a higher level of care within 6 h of hospital admission |
| • Rapid response calls within 6 h of hospital admission |
| • Rates of medication errors |
| Experiences of care |
| • Patient and family experience of care |
| • Referring clinician experience of care |
| • Inpatient team experience of care |
Conclusions
Direct admissions are relatively common in pediatrics, experienced by 1 in 4 children admitted for unscheduled hospitalizations in the United States. Direct conversations between outpatient- and inpatient-based health care professionals that are inherent to the direct admission referral process have the potential to improve transitions from outpatient to inpatient care. Concurrently, direct admissions may be associated with reduced resource utilization and decrease the strain on busy EDs. The recommendations included in this policy statement are intended to support the implementation of safe direct admission processes and to foster an awareness of outcomes associated with this common portal of hospital admission.
Lead Authors
JoAnna K. Leyenaar, MD, PhD, MPH, FAAP
Vanessa Hill, MD, FAAP
Vinh Lam, MD, FAAP
Rebecca Stern, MD
Kristin Williams Vaughan, MD, FAAP
Committee on Hospital Care, 2021–2022
Daniel A. Rauch, MD, FAAP, chairperson
Samantha House, DO, FAAP
Benson Hsu, MD, MBA, FCCM, FAAP, AAP Section on Critical Care member
Melissa Mauro-Small, MD, FAAP, AAP Section on Hospital Medicine member
Nerian Ortiz-Mato, MD, FAAP
Charles Vinocur, MD, FAAP, FACS
Nicole Webb, MD, FAAP
Former Committee on Hospital Care Member, 2019–2020
Vanessa Hill, MD, FAAP
Former Committee on Hospital Care Members,2020–2021
Kimberly Ernst, MD, MSMI, FAAPVinh Lam, MD, FAAP
Liaisons
Michael S. Leonard, MD, MS, FAAP – representative to The Joint Commission
Karen Castleberry – family representative
Nancy Hanson – Children’s Hospital Association
Kristin Hittle Gigli, PhD, RN, CPNP-AC, CCRN – National Association of Pediatric Nurse Practitioners
Barbara Romito, MA, CCLS – Association of Child Life Professionals
Staff
S. Niccole Alexander, MPP
Dr Leyenaar drafted the manuscript; and all authors participated in the concept and design, analysis and interpretation of data, and revising of the manuscript, and approved the final manuscript as submitted and agree to be accountable for all aspects the work.
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent. The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
FINANCIAL/CONFLICT OF INTEREST DISCLOSURE: Dr Leyenaar disclosed financial relationships with the American Board of Pediatrics (ABP) Foundation as a consultant. Dr Leyenaar was also supported by the Agency for Healthcare Research and Quality (K08HS024133); the content is solely the responsibility of the authors and does not necessarily represent the official views of AHRQ or the ABP Foundation.
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