Dartmouth Health, Lebanon, New Hampshire.
The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.
Pediatrics. 2024 Oct 1;154(4). doi: 10.1542/peds.2024-065776.
Direct admission (DA) to hospital can reduce emergency department (ED) utilization by bypassing the ED during the admission process. We implemented a DA program across 3 health systems and compared timeliness of care, family experience of care, and post-admission clinical deterioration among children admitted via DA versus the ED after their clinic was randomized to begin the DA program.
Using a stepped-wedge design, 69 primary and urgent care clinics were randomized to 1 of 4 time points to begin a voluntary DA program, February 1, 2020 to April 30, 2023. Outcomes in children <18 years admitted with 7 common medical diagnoses were compared using adjusted logistic or linear regression.
A total of 2599 children were admitted with eligible diagnoses during the study period , including 145 children admitted directly and 1852 admitted through EDs after program implementation at their clinic. Median age was 2.8 (interquartile range: 1.1-6.8) years, 994 (49.8%) were female, and 1324 (66.3%) were Medicaid-insured. Adjusted regression analyses showed that if each child was admitted via DA versus the ED, average time to initial clinical assessment was 3.1 minute (95% confidence interval: 1.7-4.5) slower, whereas time to initial therapeutic management was 49.6 minutes faster on average (95% confidence interval: 30.3.2-68.9). There were no significant differences in time to initial diagnostic testing or rates of post-admission clinical deterioration.
Compared with ED admission, DA appears equally safe and acceptable to families, and may be associated with a significantly shorter time to initial therapeutic management with modestly longer time to initial clinical assessment.
直接入院（DA）可以绕过入院过程中的急诊部（ED），从而减少 ED 的利用。我们在 3 个医疗系统中实施了 DA 计划，并比较了通过 DA 入院的儿童与在诊所开始 DA 计划后通过 ED 入院的儿童在护理及时性、家庭护理体验以及入院后临床恶化方面的差异。
使用阶梯式设计，将 69 个初级和紧急护理诊所随机分配到开始自愿 DA 计划的 4 个时间点之一，时间为 2020 年 2 月 1 日至 2023 年 4 月 30 日。使用调整后的逻辑或线性回归比较 7 种常见医疗诊断下 <18 岁儿童的入院结局。
在研究期间，共有 2599 名符合条件的儿童被诊断为患有这些疾病并入院，其中 145 名儿童直接入院，1852 名儿童在其诊所实施该计划后通过 ED 入院。中位年龄为 2.8 岁（四分位距：1.1-6.8），994 名（49.8%）为女性，1324 名（66.3%）为医疗补助保险。调整后的回归分析表明，如果每个儿童都通过 DA 入院而不是 ED 入院，平均初始临床评估时间将慢 3.1 分钟（95%置信区间：1.7-4.5），而平均初始治疗管理时间将快 49.6 分钟（95%置信区间：30.3-68.9）。初始诊断性检查时间或入院后临床恶化率无显著差异。
与 ED 入院相比，DA 似乎对家庭同样安全和可接受，并且可能与初始治疗管理时间显著缩短相关，而初始临床评估时间略有延长。
