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Children's Mercy Hospital

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  • So, we decided to analyze and learn from our experience with the H1N1 outbreak, to help us determine whether the Pediatric ED or the Pediatric Urgent Care Centers had been more affected, to help us make more informed decisions should something like this come up again in the future. We focused on two outcomes that we thought were the most important and simplest to measure: overall patient volume, measured by the numbers of patients registering, and rates of elopement, most of whom were patients who left before being seen, but which also includes patients who left before their evaluation was complete.
  • Our setting was Children’s Mercy Hospitals and Clinics, which has several locations throughout the Kansas City, MO area. In particular, we looked at data from our Pediatric Emergency Department and our two off-site pediatric urgent care centers. Our Pediatric ED is located in our main hospital building in Kansas City, and sees patients of all acuities who arrive at any time. The annual census at our Pediatric ED is about 70,000 patients per year. One of our pediatric urgent care centers is at our Northland facility, which is located with several other pediatric sub-specialty clinics in North Kansas City about 15 miles north of the main hospital building. The Northland Pediatric Urgent Care Center is open every day from noon- 10 PM, and has an annual census of about 23,000 patients. The other pediatric urgent care center is located about 18 miles south of the main hospital building, in a vary large multi-specialty setting that includes pediatric clinics, in-patient beds, ORs, and so forth. This South Pediatric Urgent Care Center is always open, and sees about 55,000 patients per year.
  • We defined our data collection period a bit on the generous side, to try to capture the entire event, as being from August 1 st -- Nov 15 th of 2009. Using the administrative database generated by our computerized patient tracking system, we compared data on patient registration and patient elopement rates from the outbreak period with data from the same dates, August 1 st -- Nov 15 th of 2008. We combined data from the two Pediatric Urgent Care sites. We did have to make one fairly small but important adjustment to the data that I want to be sure to explain. In July of 2009, just before the H1N1 outbreak, we had expanded the hours of operation of the Northland Pediatric Urgent Care Center, which is the one that sees about 30% of our total urgent care patients. Thus, in order to have a fair year-over-year volume comparison, we adjusted the 2008 Northland volume upward. In order to figure out how much to adjust it by, we compared patient volumes at that center for the four full months AFTER the H1N1 outbreak with the corresponding four months a year earlier, which showed an 8.6% increase. Thus, we adjusted our 2008 baseline volume at the smaller, Northland Pediatric Urgent Care Center upwards by 8.6%, to make the comparison with 2009 as fair as we could.

Children's Mercy Hospital Children's Mercy Hospital Presentation Transcript

  • Was the Pediatric Emergency Department or Pediatric Urgent Care Center Setting More Affected by the Fall, 2009 H1N1 Influenza Outbreak? G. Conners, MD, MPH, MBA; T. Hartman, MHA; M. Fowler, MD; L. Schroeder, MD; T. Tryon, MD Children’s Mercy Hospitals & Clinics, Kansas City, MO
  • Background
    • The H1N1 influenza outbreak of Fall, 2009 stressed the resources of our pediatric emergency department (PED) and two pediatric urgent care centers (PUCCs).
    • As the leaders of the Division that manages both areas, we had to make PED versus PUCC resource allocation decisions based on guesswork, rather than data.
  • Background
    • We sought to learn from our experience, in order to determine whether the PED or the PUCC setting had been more affected, to help guide future decision-making.
    • Our areas of focus for this analysis:
      • overall volumes (# patients registering)
      • rates of elopement (either left before seen or during evaluation)
  • Setting
    • Free-standing, academic children’s hospital in Kansas City, MO:
      • Main hospital: ~70,000 annual visit PED
      • Northland: multiple pediatric sub-specialty clinics in North K.C., including a noon-10 PM PUCC (~23,000 / yr)
      • South: multiple pediatric sub-specialty clinics / inpatient beds in Overland Park, KS, including a 24/7/365 PUCC (~55,000 / yr)
  • Methods
    • Fall, 2009 H1N1 influenza outbreak period: 8/1/09 – 11/15/09
    • Using an administrative database, we compared patient data during this period with those of the same dates in 2008 :
      • Patients who registered * (volume)
      • Rates of patients who eloped (either left before seen or during evaluation)
      • We combined data from the two PUCC sites
      • *We adjusted (increased) the Fall, 2008 Northland PUCC volume by 8.6%, to account for increased service hours in Fall, 2009 versus Fall, 2008 (adjustment determined by comparing 12/09-3/10 with 12/08-3/09)
  • Methods
    • We statistically compared overall patient volumes using chi-square test, and changes in elopement rates using Poisson regression.
    • Our IRB deemed this a quality improvement project, not subject to IRB approval.
  • Results: Volume PUCC increase > PED increase p<.0001 # patients 2008 2009 (H1N1) Increase PED 18,575 21,805 3230 (17.4%) PUCC 19,431 * 24,488 5057 (26.0%)
  • Results: Elopement Rates PUCC rate increase > PED rate increase p<.0001 # patients 2008 2009 (H1N1) Absolute Increase (rate increase) PED 698 (3.8%) 1296 (5.9%) 598 (58%) PUCC 227 (1.2%) * 779 (3.2%) 552 (172%)
  • Results
    • Both the PED and PUCC settings experienced substantial surges in patient volume and elopement rates during the Fall, 2009 H1N1 influenza outbreak.
  • Results: Volume
    • The PUCC setting had both a larger absolute increase (5057 versus 3230) and relative increase (26.0% versus 17.4%) in patient volume than did the PED during the Fall, 2009 H1N1 influenza outbreak.
  • Results: Elopement Rates
    • The PUCC setting had a larger elopement rate increase (172% for PUCC versus 58% for PED) and nearly as large an absolute elopement increase (552 for PUCC versus 598 for PED) than did the PED during the Fall, 2009 H1N1 influenza outbreak.
  • Discussion
    • Q: Was the PED or the PUCC setting more affected by the Fall, 2009 H1N1 influenza outbreak?
    • A: The PUCC!
  • Discussion
    • This suggests that, when allocating resources between the PED and the PUCC during a large-scale influenza (or similar) outbreak, the PUCC should receive a substantial, and perhaps a majority, share.
  • Two Major Limitations
    • We have measured and compared the quantity , not the quality , of the effects of the Fall, 2009 H1N1 outbreak on PED and the PUCC.
    • Related issues:
    • who came to each setting for care
    • acuity differences
    • who eloped, and why? , etc.
  • Two Major Limitations
    • Inherent limitations of our research design: before-after study using an administrative database.
    • Related issues:
    • changes in other factors between 2008 / 2009?
    • accuracy of administrative data?
    • the baseline adjustment we made, etc.
  • Conclusions
    • Both the PED and PUCC were very affected by the Fall, 2009 H1N1 influenza outbreak.
    • In terms of volume of patients seen and increase in elopement rates, the PUCC setting was more affected than the PED setting .
    • Although not the whole story, given the limitations, this information will be useful when allocating resources in future, similar situations.
  • Thank you!
  • Thank you! Questions?