Use of Observation Unit and Home Oxygen Therapy to Decrease LOS

The most common reason for hospitalization of children <1 year of age in the United States is bronchiolitis, accounting for 150,000 admissions per year with a mean length of stay (LOS) of 3.3 days. Although hospital treatment for bronchiolitis is primarily supportive care, management of inpatients amounts to substantial healthcare use. Previous studies have found that the introduction of standardized practice guidelines for bronchiolitis can reduce unnecessary interventions and shorten hospital LOS.

For common illnesses previously treated in an inpatient setting, pediatric observation units (OUs) offer an opportunity to safely and efficiently provide care, according to researchers. Noting that home oxygen therapy (HOT) has been used to facilitate hospital discharge in patients with hypoxic bronchiolitis, the researchers designed a study to test the hypothesis that using OU-HOT for bronchiolitis would decrease LOS. They reported study results online in JAMA Pediatrics [doi:10.100/jamapediatrics.2013.1435].

The participants in the retrospective cohort study were patients <2 years of age with uncomplicated bronchiolitis admitted to the Primary Children’s Medical Center in Salt Lake City, Utah, during the winter seasons of 2005 through 2011. The intervention studied was the implementation of a new bronchiolitis care process that encouraged use of an OU-HOT protocol.

The main outcome measures were mean hospital LOS, discharge within 24 hours, emergency department (ED) bronchiolitis admission rates, ED revisit/readmission rates, and inflation-adjusted cost.

The analysis compared 692 patients with bronchiolitis from the 2010-2011 bronchiolitis season (after implementation of the OU-HOT protocol) with 725 patients from the 2009-2010 season (before implementation of the OU-HOT protocol). The cohorts differed significantly in the male to female ratio and proportion of publicly insured and self-pay patients. Mean age was 7.5 months in the 2009-2010 cohort and 7.1 months in the 2010-2011 cohort (P<.03).

Following implementation of the OU-HOT protocol, the mean LOS decreased from 63.3 hours to 49.3 hours (P<.001). There were similar decreases in median LOS values, both before and after covariate adjustment. Implementation of the OU-HOT protocol also led to a significant increase in the proportion of patients discharged within 24 hours, from 20.0% in the 2009-2010 cohort to 38.4% in the 2010-2011 cohort (P<.001).

There were no differences in ED bronchiolitis admission rates or ED revisit/readmission rates between the 2 cohorts.

Following implementation of the OU-HOT protocol, total cost per admitted case decreased by 25.4%, from $4800 in the 2009-2010 cohort to $3582 in the 2010-2011 cohort (P<.001). The proportion of patients who were discharged receiving HOT increased from 35% to 46% for 93 additional patients on home oxygen support. Costs for supplemental oxygen, including tank delivery and pick-up, were estimated at $22 per case across the entire cohort.

In summary, the researchers said, “Implementation of an OU-HOT protocol for patients with bronchiolitis safely reduces hospital LOS with significant cost savings. Although widespread implementation has the potential for dramatic cost savings nationally, further studies assessing overall healthcare use and cost, including the impact on families and outpatient practices, are needed.”