Structure and Function of Observation Units in Children's Hospitals: A Mixed-Methods Study



      Observation unit (OU) use has been promoted recently to decrease resource utilization and costs for select patients, but little is known about the operations of pediatric OUs. This study aimed to characterize the infrastructure and function of OUs within freestanding children's hospitals and to compare characteristics between hospitals with and without OUs.


      All 43 freestanding children's hospitals that submit data to the Pediatric Health Information System were contacted in 2013 to identify OUs that admitted unscheduled patients from their emergency department (ED) in 2011. Semistructured interviews were conducted with representatives at hospitals with these OUs. Characteristics of hospitals with and without OUs were compared.


      Fourteen (33%) of 43 hospitals had an OU during 2011. Hospitals with OUs had more beds and more annual ED visits compared to those without OUs. Most OUs (65%) were located in the ED and had <12 beds (65%). Staffing models and patient populations differed between OUs. Nearly 60% were hybrid OUs, providing scheduled services. OUs lacked uniform outcome measures. Themes included: admissions were intuition based, certain patients were not well suited for OUs, OUs had rapid-turnover cultures, and the designation of observation status was arbitrary. Challenges included patient discontent with copayments and payer-driven utilization reviews.


      OUs were located in higher volume hospitals and varied by location, size, and staffing. Most functioned as hybrid OUs. OUs based admissions on intuition, had staffing cultures centered on rapid turnover of patient care, lacked consistent outcome measures, and faced challenges regarding utilization review and patient copayments.


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        • Macy M.L.
        • Stanley R.M.
        • Lozon M.M.
        • et al.
        Trends in high-turnover stays among children hospitalized in the United States, 1993–2003.
        Pediatrics. 2009; 123: 996-1002
        • Macy M.L.
        • Stanley R.M.
        • Sasson C.
        • et al.
        High turnover stays for pediatric asthma in the United States: analysis of the 2006 Kids' Inpatient Database.
        Med Care. 2010; 48: 827-833
        • Baugh C.W.
        • Venkatesh A.K.
        • Bohan J.S.
        Emergency department observation units: a clinical and financial benefit for hospitals.
        Health Care Manage Rev. 2011; 36: 28-37
        • Baugh C.W.
        • Venkatesh A.K.
        • Hilton J.A.
        • et al.
        Making greater use of dedicated hospital observation units for many short-stay patients could save $3.1 billion a year.
        Health Aff (Millwood). 2012; 31: 2314-2323
        • Jagminas L.
        • Partridge R.
        A comparison of emergency department versus inhospital chest pain observation units.
        Am J Emerg Med. 2005; 23: 111-113
        • Wiler J.L.
        • Ross M.A.
        • Ginde A.A.
        National study of emergency department observation services.
        Acad Emerg Med. 2011; 18: 959-965
        • Ross M.A.
        • Aurora T.
        • Graff L.
        • et al.
        State of the art: emergency department observation units.
        Crit Pathw Cardiol. 2012; 11: 128-138
        • Gururaj V.J.
        • Allen J.E.
        • Russo R.M.
        Short stay in an outpatient department. An alternative to hospitalization.
        Am J Dis Child. 1972; 123: 128-132
        • Wiley 2nd, J.F.
        • Friday J.H.
        • Nowakowski T.
        • et al.
        Observation units: the role of an outpatient extended treatment site in pediatric care.
        Pediatr Emerg Care. 1998; 14: 444-447
        • Silvestri A.
        • McDaniel-Yakscoe N.
        Observation medicine: the expanded role of the nurse practitioner in a pediatric emergency department extended care unit.
        Pediatr Emerg Care. 2005; 21: 199-202
        • Thomas D.O.
        Our new rapid treatment unit: an innovative adaptation of the “less than 24-hour stay” holding unit.
        J Emerg Nurs. 2000; 26: 507-513
        • Macy M.L.
        • Kim C.S.
        • Sasson C.
        • et al.
        Pediatric observation units in the United States: a systematic review.
        J Hosp Med. 2010; 5: 172-182
        • Conners G.P.
        • Melzer S.M.
        • Committee on Hospital Care; Committee on Pediatric Emergency Medicine
        • et al.
        Pediatric observation units.
        Pediatrics. 2012; 130: 172-179
        • Macy M.L.
        • Hall M.
        • Shah S.S.
        • et al.
        Designations of observation care in US freestanding children's hospitals: are they virtual or real?.
        J Hosp Med. 2012; 7: 287-293
        • Zebrack M.
        • Kadish H.
        • Nelson D.
        The pediatric hybrid observation unit: an analysis of 6477 consecutive patient encounters.
        Pediatrics. 2005; 115: e535-e542
        • Ross M.A.
        • Naylor S.
        • Compton S.
        • et al.
        Maximizing use of the emergency department observation unit: a novel hybrid design.
        Ann Emerg Med. 2001; 37: 267-274
        • Gouin S.
        • Macarthur C.
        • Parkin P.C.
        • et al.
        Effect of a pediatric observation unit on the rate of hospitalization for asthma.
        Ann Emerg Med. 1997; 29: 218-222
        • Graff L.
        The Textbook of Observation Medicine: The Healthcare System's Tincture of Time.
        American College of Emergency Physicians, Irving, Tex2010 (Available at:) (Accessed December 26, 2014)
        • Sherwood K.
        • Sugerman S.
        • Bossart P.
        • et al.
        EDOU staffing by PAs: what are the effects on patient outcomes?.
        JAAPA. 2011; 24 (37): 31-34
        • Leykum L.K.
        • Huerta V.
        • Mortensen E.
        Implementation of a hospitalist-run observation unit and impact on length of stay (LOS): a brief report.
        J Hosp Med. 2010; 5: E2-E5
        • Alpern E.R.
        • Calello D.P.
        • Windreich R.
        • et al.
        Utilization and unexpected hospitalization rates of a pediatric emergency department 23-hour observation unit.
        Pediatr Emerg Care. 2008; 24: 589-594
        • Scribano P.V.
        • Wiley 2nd, J.F.
        • Platt K.
        Use of an observation unit by a pediatric emergency department for common pediatric illnesses.
        Pediatr Emerg Care. 2001; 17: 321-323
        • Mallory M.D.
        • Kadish H.
        • Zebrack M.
        • et al.
        Use of a pediatric observation unit for treatment of children with dehydration caused by gastroenteritis.
        Pediatr Emerg Care. 2006; 22: 1-6
        • Calello D.P.
        • Alpern E.R.
        • McDaniel-Yakscoe M.
        • et al.
        Observation unit experience for pediatric poison exposures.
        J Med Toxicol. 2009; 5: 15-19
        • Sandweiss D.R.
        • Corneli H.M.
        • Kadish H.A.
        Barriers to discharge from a 24-hour observation unit for children with bronchiolitis.
        Pediatr Emerg Care. 2010; 26: 892-896
        • Greenberg R.A.
        • Dudley N.C.
        • Rittichier K.K.
        A reduction in hospitalization, length of stay, and hospital charges for croup with the institution of a pediatric observation unit.
        Am J Emerg Med. 2006; 24: 818-821
        • Ross M.A.
        • Hockenberry J.M.
        • Mutter R.
        • et al.
        Protocol-driven emergency department observation units offer savings, shorter stays, and reduced admissions.
        Health Aff (Millwood). 2013; 32: 2149-2156
        • Waters J.
        • Hall J.
        Staff satisfaction in short stay wards.
        Aust Health Rev. 1988; 11: 302-310
        • Walsh M.
        • Knott J.C.
        Satisfaction with the emergency department environment decreases with length of stay.
        Emerg Med J. 2010; 27: 821-828
        • Chandra A.
        • Sieck S.
        • Hocker M.
        • et al.
        An observation unit may help improve an institution's Press Ganey satisfaction score.
        Crit Pathw Cardiol. 2011; 10: 104-106
        • Rydman R.J.
        • Roberts R.R.
        • Albrecht G.L.
        • et al.
        Patient satisfaction with an emergency department asthma observation unit.
        Acad Emerg Med. 1999; 6: 178-183
      1. Danbury Hospital (Danbury, Conn). Patient education sheet: outpatient observation status. Available at:∼/media/Files/Patient%20Education/patiented-english/pdf_Other/Observation%20Unit%20Patient%20Fact%20Sheet.ashx. Accessed December 26, 2014.

      2. Lenoir Memorial Hospital (Kinston, NC). Outpatient observation FAQ. Available at: Accessed December 26, 2014.

      3. Hancock Regional Hospital (Greenfield, Ind). Billing FAQ. Available at: Accessed December 26, 2014.

        • Baugh C.W.
        • Schuur J.D.
        Observation care—high-value care or a cost-shifting loophole?.
        N Engl J Med. 2013; 369: 302-305
        • Schappert S.M.
        • Bhuiya F.
        Availability of pediatric services and equipment in emergency departments: United States, 2006.
        Natl Health Stat Report. 2012; 1: 1-21