PECARN obs group

[migm]

Trying to get a sense for others' practice. For those for whom OBS vs CT is recommended and observation is chosen, do you all admit these patients to the hospital? Discharge home with close parental observation? Time/day of week dependent? Hospitalist dependent?

In residency we sent these kids home as long as they didn't meet criteria for CT with parental observation regardless, but at my new place we are apparently admitting all these kids to the hospital. Wanted to hear how conservative this way in comparison to others.

M

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[turkeyjerky]

Trying to get a sense for others' practice. For those for whom OBS vs CT is recommended and observation is chosen, do you all admit these patients to the hospital? Discharge home with close parental observation? Time/day of week dependent? Hospitalist dependent?

In residency we sent these kids home as long as they didn't meet criteria for CT with parental observation regardless, but at my new place we are apparently admitting all these kids to the hospital. Wanted to hear how conservative this way in comparison to others.

M

I usually obs in ED for 2-3 hrs and ensure they take PO. I think admitting to the hospital is overkill unless they have persistent vomiting or AMS (in which case they'd usually get a CT I the ER and symptomatic treatment, and likely obviate the need for admission). Obviously, concern over abisive head trauma or unreliable parents would entail a different path, but again I'd probably just CT those patients.

 

[migm]

I usually obs in ED for 2-3 hrs and ensure they take PO. I think admitting to the hospital is overkill unless they have persistent vomiting or AMS (in which case they'd usually get a CT I the ER and symptomatic treatment, and likely obviate the need for admission). Obviously, concern over abisive head trauma or unreliable parents would entail a different path, but again I'd probably just CT those patients.

3 hours obs in the ED is kinda rough on ye old dispo times..

 

[xaelia]

I've never heard of hospital admission re: observation for minor head injury in the "grey area" of PECARN. Usually after a couple hours in the ED, a snack, and lots of reassurance, everyone's ready to go home. I've had a couple change behavior/recurrent vomiting and progress to CT – but none have yet been positive.

 

[Angry Birds]

I use a very loose definition of "observe." It usually just means the time it takes to see any remaining patients, write the chart, get the discharge paperwork ready, and swing by a second time to say "hi" to the patient and do a quick exam.

 

[gman33]

I give parents choice of ct or 4 hour ed obs.
I've never heard of admitting, but if ed space is limited and they get admitted quickly, not a terrible idea.

My guess is your shop had a bad outcome and this was the "fix".

 

[WilcoWorld]

I Obs in the ED. Now that I think about it, we could probably bill for an Obs admission when doing this, but I've never bothered.

I think it comes down to your local situation - if you can get kids upstairs quickly, and beds are at a premium in your ED, then it makes sense to admit (assuming your Peds floor is comfortable with frequent neuro checks). But I suspect that in most places, it'll take so long to process the admission that the kid's essentially ready to go home as soon as he hits the floor.

 

[migm]

Yeah our peds admissions are *very* snappy (door to bed upstairs can be had in <1hr >90% of the time), ED beds at a preminum.. I wish our non-peds admissions were even a fraction as efficient.

 

[Janders]

Yeah I usually watch these 2-4hr in the ED (we don't admit peds where I am).
If they are soft calls, reliable social structure, and live right down the street I'm very comfortable with the lower end of this number.

 

[Angry Birds]

This is the one of the many reasons why I don't support this obsession with throughput times/metrics. It leads to poor care, i.e. discharging patients before what might be optimal.

 

[migm]

This is the one of the many reasons why I don't support this obsession with throughput times/metrics. It leads to poor care, i.e. discharging patients before what might be optimal.

Agree with you.. but what the heck is the "optimal" observation period for the intermediate risk group?

 

[Angry Birds]

Agree with you.. but what the heck is the "optimal" observation period for the intermediate risk group?

Whenever I return with the discharge paperwork.

 

[migm]

Whenever I return with the discharge paperwork.

Which is interesting when you think about the fact that I'll be admitting these pts to the hospital

 

[emergentmd]

I either CT if concerned then discharge. If pt looks well, they go home. Never Obs a kids for 3+ hrs in my life. I have 3 kids, and to have young kids OBS in the ED for 3+ seems crazy.

But I have heard of hospitals that Admit all head trauma (even minor) for pts on Coumadin with therapeutic INR or Xarelto-alike.

 

[shoal007]

I either CT if concerned then discharge. If pt looks well, they go home. Never Obs a kids for 3+ hrs in my life. I have 3 kids, and to have young kids OBS in the ED for 3+ seems crazy.

But I have heard of hospitals that Admit all head trauma (even minor) for pts on Coumadin with therapeutic INR or Xarelto-alike.

well both of these (minor head trauma on anticoag and children without imaging) have likely similar bleeding risk (coumadin delayed 0.5%). both are reasonable. as for observation billing, you need 8 hours to bill for it, not gonna happen in peds.

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[emergentmd]

well both of these (minor head trauma on anticoag and children without imaging) have likely similar bleeding risk (coumadin delayed 0.5%). both are reasonable. as for observation billing, you need 8 hours to bill for it, not gonna happen in peds.

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I never said they were unreasonable. Every EM doc has to decide what they are comfortable with. I just find it crazy to Obs a Kid with head trauma or CT them unless there is some concern. My kids fall and hit there heads all of the time with bruises. I dont take them to the ED and would never let someone keep them for 3+ to watch them. May I miss a small bleed? Sure. Will they do fine without any intervention? MOST will.

Minor head trauma + coumadin = CT is appropriate. But to Obs them overnight with another CT is plain unreasonable IMO. That would be like admitting everyone over 40 with atypical chest pain for a Cath. I am sure if you cath all 40 yr old with atypical CP, 1 in 200 would have something that needs to be stented.

But that doesn't mean we need to cath them all.

 

[RustedFox]

The little rodents can be obs'ed in the home by their 'rents. I document (auto text) that the family and I discussed at length what to watch out for and when to immediately return, and that parent is comfortable with this (as opposed to in Dept observation) and is judged to be a reliable caregiver.

 

[Daiphon]

The little rodents can be obs'ed in the home by their 'rents. I document (auto text) that the family and I discussed at length what to watch out for and when to immediately return, and that parent is comfortable with this (as opposed to in Dept observation) and is judged to be a reliable caregiver.

I count all time since injury (dillydallying at home, waiting to be seen, etc) as obs... if at least 3-4h since FDGB, then bye-bye. If not, I make up the difference, then bye-bye. d=)

Semper Brunneis Pallium

 

[turkeyjerky]

I never said they were unreasonable. Every EM doc has to decide what they are comfortable with. I just find it crazy to Obs a Kid with head trauma or CT them unless there is some concern. My kids fall and hit there heads all of the time with bruises. I dont take them to the ED and would never let someone keep them for 3+ to watch them. May I miss a small bleed? Sure. Will they do fine without any intervention? MOST will.

I think you're referring the 'no-risk' group of patients. I agree, kids with a fall and a goose egg get discharged immediately. Obs period is recommended for patients with concerning features or severe mechanism:

Age >2: history of LOC, vomiting, severe headache

Age< 2: loc>5 sec, large non-frontal hematoma, or not acting normally in ED

If they don't have any of those, then they get discharged immediately.

 

[shookwell]

I am happy to work in a place where no one bothers us about dispo times. I will obs a kid in the ED for as many hours as I think they need. With reliable parents who understand what's going on I will discharge and "obs" at home. But if the parents don't seem reliable or something seems off I have no problem keeping the kid in the ED for 8 hours before discharge.

 

[emergentmd]

I think you're referring the 'no-risk' group of patients. I agree, kids with a fall and a goose egg get discharged immediately. Obs period is recommended for patients with concerning features or severe mechanism:

Age >2: history of LOC, vomiting, severe headache

Age< 2: loc>5 sec, large non-frontal hematoma, or not acting normally in ED

If they don't have any of those, then they get discharged immediately.

I agree. LOC is usually a CT head for me unless the parents are refusing and willing to watch the kids closely. But again, I never Obs a Kid even in this group for 3+ hrs.

 

[engineeredout]

We tend to CT a lot of the OBS vs CT group. We don't have Peds in house. I thought it was just us but when I was on a PEM rotation a few months ago at a major children's hospital - they scanned a decent amount of the obs group too.

Depends on the parents too. If they're reasonable people you can have the discussion about ct risks vs observation. If they're unreasonable/hysterical/stupid, probably just gonna do the scan.

 

[Rendar5]

1 to 2 hours and then go home to parents for home obs if they are comfortable. Patients should be observed until six hours post injury by parents or myself. I rarely have anyone switch into the CT group from the obs group. I have only had that happen three times in my career. One out of the three had a bleed. I have 1-2 patients a year who decline obs in favor of CT. I can't admit peds so the answer of whether to admit or watch in the ED is an easy one for me.

 

[Welker]

at our institution we would just obs the kid 2-3hr or so and send home if all goes well. would be very unusual to admit these kids