Paediatric admissions rising

Strategies designed to reduce hospital admission appear to have failed.

The number of acute paediatric admissions to hospital is increasing in Australia and other developed countries.

This has implications for local medical expertise, changing styles of medical practice with regard to on-call services and cost to the healthcare system.

The reasons for this are not easily identified, but it has been suggested that contributory factors may include increasing clinician concerns about medico-legal claims, lower admission thresholds from less experienced junior doctors in emergency departments and an increase in parental expectations of admission. 

As a result, hospitals have responded by increasing the number of staff in emergency departments, developing short-stay wards attached to emergency departments and having next day review consultant clinics and prioritised follow-up with paediatricians and paediatric subspecialists. 

Having implemented these changes in the UK, which shares a universal healthcare system model like Australia (albeit with some differences with regard to general practice organisation), a recent systematic review was undertaken by Coon and colleagues to look for evidence of the impact of such initiatives on healthcare outcomes.

Published in Archives of Disease in Childhood, the review highlighted the limited evidence available (only seven studies) for the expensive interventions undertaken. 

The first interesting outcome was that the authors found no evidence that the use of algorithms and guidelines to manage the admission decision was effective in reducing admission rates. This is in contrast to a number of centres that have pushed the concept of algorithms for certain conditions, such as asthma or fever in young children, where they have had some success. 

However, perhaps the common limitation could be the clinical experience of the person using the algorithms. The second outcome of the review considered this possibility and unfortunately the authors found no studies that addressed the effects on admission, rates of admission decision by the paediatric consultant, telephone triage by the consultant or the establishment of next day emergency paediatric clinics. 

One confounder was the issue of changing definitions of what constitutes a hospital admission between countries. This is interesting in the local context as pressure continues to mount on hospital budgets and funding moves revolve around the case mix of patients seen. Under such a system there can potentially be a financial incentive to classify a patient as an admission rather than an occasion of service (or consultation) within the emergency department.

This should not be seen as a criticism of staff in emergency departments who are exceptionally busy, usually understaffed and often under resourced.

There are insufficient beds in the hospital and limited resources available to review the patients on weekends within the community. In addition patients and families are stressed and anxious. 

So what is the answer? Perhaps more money in the system to provide the resources that are lacking would be a simplistic suggestion but nonetheless a good place to start. If you ask the clinicians rather than the health administrators, this would mean more targeted facilities in the community. 

This is not the same as a handful of GP super clinics in a few marginal electorates. 

A more effective and economical resource would be located in busy areas with many young families where sufficient numbers of appropriately trained and paid doctors and allied health staff in the community could see patients after hours with the support of paediatric staff working in hospital paediatric and mixed adult and paediatric emergency departments.

Coon, JT et al. ADC online: 10.1136/archdischild-2011-301214

Clinical Professor Dominic Fitzgerald

MBBS, PhD, FRACP

Paediatric respiratory and sleep physician at The Children’s Hospital at Westmead, NSW.