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 1st -- Nov 15th 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 1st -- Nov 15th 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.
Was the Pediatric EmergencyWas the Pediatric Emergency
Department or Pediatric UrgentDepartment or Pediatric Urgent
Care Center Setting MoreCare Center Setting More
Affected by the Fall, 2009 H1N1Affected by the Fall, 2009 H1N1
Influenza Outbreak?Influenza Outbreak?
G. Conners, MD, MPH, MBA; T.G. Conners, MD, MPH, MBA; T.
Hartman, MHA; M. Fowler, MD; L.Hartman, MHA; M. Fowler, MD; L.
Schroeder, MD; T. Tryon, MDSchroeder, MD; T. Tryon, MD
Children’s Mercy Hospitals &Children’s Mercy Hospitals &
Clinics, Kansas City, MOClinics, Kansas City, MO
The H1N1 influenza outbreak of Fall,The H1N1 influenza outbreak of Fall,
2009 stressed the resources of our2009 stressed the resources of our
pediatric emergency departmentpediatric emergency department
(PED) and two pediatric urgent care(PED) and two pediatric urgent care
centers (PUCCs).centers (PUCCs).
As the leaders of the Division thatAs the leaders of the Division that
manages both areas, we had tomanages both areas, we had to
make PED versus PUCC resourcemake PED versus PUCC resource
allocation decisions based onallocation decisions based on
guesswork, rather than data.guesswork, rather than data.
We sought to learn from ourWe sought to learn from our
experience, in order to determineexperience, in order to determine
whether the PED or the PUCCwhether the PED or the PUCC
setting had been more affected, tosetting had been more affected, to
help guide future decision-making.help guide future decision-making.
Our areas of focus for this analysis:Our areas of focus for this analysis:
overall volumes (# patientsoverall volumes (# patients
rates of elopement (either left beforerates of elopement (either left before
seen or during evaluation)seen or during evaluation)
Free-standing, academic children’sFree-standing, academic children’s
hospital in Kansas City, MO:hospital in Kansas City, MO:
Main hospital:Main hospital: ~70,000 annual visit
Northland:Northland: multiple pediatric sub-
specialty clinics in North K.C.,
including a noon-10 PM PUCC
(~23,000 / yr)
South:South: multiple pediatric sub-specialty
clinics / inpatient beds in Overland
Park, KS, including a 24/7/365 PUCC
(~55,000 / yr)
Fall, 2009 H1N1 influenza outbreakFall, 2009 H1N1 influenza outbreak
period: 8/1/09 – 11/15/09period: 8/1/09 – 11/15/09
Using an administrative database, weUsing an administrative database, we
compared patient data during this periodcompared patient data during this period
with those of the same dates in 2008with those of the same dates in 2008:
Patients who registeredPatients who registered** (volume)(volume)
Rates of patients who eloped (eitherRates of patients who eloped (either
left before seen or during evaluation)left before seen or during evaluation)
We combined data from the two PUCCWe combined data from the two PUCC
*We adjusted (increased) the Fall, 2008 Northland PUCC*We adjusted (increased) the Fall, 2008 Northland PUCC
volume by 8.6%, to account for increased servicevolume by 8.6%, to account for increased service
hours in Fall, 2009 versus Fall, 2008 (adjustmenthours in Fall, 2009 versus Fall, 2008 (adjustment
determined by comparing 12/09-3/10 with 12/08-3/09)determined by comparing 12/09-3/10 with 12/08-3/09)
We statistically compared overallWe statistically compared overall
patient volumes using chi-squarepatient volumes using chi-square
test, and changes in elopementtest, and changes in elopement
rates using Poisson regression.rates using Poisson regression.
Our IRB deemed this a qualityOur IRB deemed this a quality
improvement project, not subject toimprovement project, not subject to
IRB approval.IRB approval.
Both the PED and PUCCBoth the PED and PUCC
settings experiencedsettings experienced
substantial surges in patientsubstantial surges in patient
volume and elopement ratesvolume and elopement rates
during the Fall, 2009 H1N1during the Fall, 2009 H1N1
influenza outbreak.influenza outbreak.
The PUCC setting had both aThe PUCC setting had both a
larger absolute increase (5057larger absolute increase (5057
versus 3230) and relativeversus 3230) and relative
increase (26.0% versus 17.4%)increase (26.0% versus 17.4%)
in patient volume than did thein patient volume than did the
PED during the Fall, 2009 H1N1PED during the Fall, 2009 H1N1
influenza outbreak.influenza outbreak.
Results: Elopement Rates
The PUCC setting had a largerThe PUCC setting had a larger
elopement rate increase (172%elopement rate increase (172%
for PUCC versus 58% for PED)for PUCC versus 58% for PED)
and nearly as large an absoluteand nearly as large an absolute
elopement increase (552 forelopement increase (552 for
PUCC versus 598 for PED) thanPUCC versus 598 for PED) than
did the PED during the Fall,did the PED during the Fall,
2009 H1N1 influenza outbreak.2009 H1N1 influenza outbreak.
Q: Was the PED or the PUCCQ: Was the PED or the PUCC
setting more affected by thesetting more affected by the
Fall, 2009 H1N1 influenzaFall, 2009 H1N1 influenza
A: The PUCC!A: The PUCC!
This suggests that, whenThis suggests that, when
allocating resources betweenallocating resources between
the PED and the PUCC during athe PED and the PUCC during a
large-scale influenza (or similar)large-scale influenza (or similar)
outbreak, the PUCC shouldoutbreak, the PUCC should
receive a substantial, andreceive a substantial, and
perhaps a majority, share.perhaps a majority, share.
Two Major Limitations
1.1. We have measured and comparedWe have measured and compared
thethe quantityquantity, not the, not the qualityquality, of the, of the
effects of the Fall, 2009 H1N1effects of the Fall, 2009 H1N1
outbreak on PED and the PUCC.outbreak on PED and the PUCC.
Related issues:Related issues:
who came to each setting for carewho came to each setting for care
acuity differencesacuity differences
who eloped, and why? , etc.who eloped, and why? , etc.
Two Major Limitations
2.2. Inherent limitations of ourInherent limitations of our
research design: before-afterresearch design: before-after
study using an administrativestudy using an administrative
Related issues:Related issues:
changes in other factors betweenchanges in other factors between
2008 / 2009?2008 / 2009?
accuracy of administrative data?accuracy of administrative data?
the baseline adjustment we made,the baseline adjustment we made,
Both the PED and PUCC were veryBoth the PED and PUCC were very
affected by the Fall, 2009 H1N1 influenzaaffected by the Fall, 2009 H1N1 influenza
In terms of volume of patients seen andIn terms of volume of patients seen and
increase in elopement rates, theincrease in elopement rates, the PUCCPUCC
setting was more affected than the PEDsetting was more affected than the PED
Although not the whole story, given theAlthough not the whole story, given the
limitations, this information will be usefullimitations, this information will be useful
when allocating resources in future,when allocating resources in future,
similar situations.similar situations.