Background: Pediatric (ped) short stay admissions of <24 hrs or 1 day (shst) are coming under increasing scrutiny due to changes in payment and the use of observation status (obs). Inpatient admission is defined by Medicare as "expected to need more than 2 midnights of medically necessary hospital care". Obs has been interpreted as care <2 midnights. Fieldston (2013) demonstrated similar resource utilization for ped obs versus regular admissions. Shanley (2015) showed variation in ped obs units. Both studies were in children's hospitals. Little data exists on ped shst patients in community hospitals. The objective was to describe ped shst at a community hospital.
Methods: As part of an ongoing QI project between billing and Pediatrics at Elmhurst Hospital Center (EHC), a NYC public hospital, all shst are reviewed for medical necessity. EHC has a 19 bed ped unit and provides acute medical and surgical services but no tertiary care. EHC annual ped LOS average is 2d +/- .2 and has a CMI .60. Surveillance of shst started on May 1, 2015 and is ongoing. This report covers 5/1/15-10/15/15. Cases were reviewed for diagnosis (dx), necessity, and potential reclassification to obs or ambulatory surgery (amb surg). All admitted ped surgical cases are admitted to ped.
Results: Shst was 60% (314/525) of total admissions over the study period. 22% (68/314) were not medically necessary. Few of those (12) were for services unavailable at night such as EEG, US or MRI. 21% (66/314) could be classified as ambulatory surgery (amb surg) with most being uncomplicated appendectomies (35) or fracture reductions (26). 24% (76/314) were medical dx that were predictable as needing <2 midnights of care such as croup, seizure, and hyperbilirubinemia. 33% (104/314) were justifiable as admissions with most common dx being respiratory (49/104). Only 4 were transferred to another facility. Amb surg plus obs accounted for 27% (142/525) of total admissions.
Conclusions: Changing reimbursement for shst cases will greatly impact our pediatric service by decreasing revenue for the same amount of work. The percent impact of total cases and likely billing exceeds that reported for tertiary care children’s hospitals. Adding 24/7 availability of some services will greatly add cost without changing the volume of shst cases. Our setting is generalizable to similar community hospitals across the country in terms of case mix and volume. Community hospital pediatric services are at great financial risk from obs status.