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Editor,—The article by Beverley et al was most interesting in clearly detailing the planning and implementation of a successful day assessment unit in a general paediatric unit.1 We agree that short stay observation wards staffed by paediatricians are an appropriate development, but the authors have not presented sufficient evidence to show that such development was associated with a reduction in the number of acute referrals that require an overnight stay. The presence of a day assessment unit may be associated with an increase in the number of acute paediatric referrals that do not require overnight admission without greatly affecting the numbers of children who require a longer stay—that is, the generation of a new daytime paediatric workload that may be unnecessary. The authors do not mention follow up care in the home environment through home care nursing staff or primary care physicians, which might reduce the need for overnight stay in hospital or re-attendance in hospital. In addition, the authors compare their figures on referrals not admitted overnight with figures on “inappropriate” admissions from other units, suggesting that all these referrals would have constituted inappropriate admissions in other units, which is clearly not the case.
At our hospital, where we do not yet have a day unit, we have conducted an audit of acute general paediatric referrals from general practitioners that are sent home without overnight admission. In one month (March/April 1997) of 207 acute referrals studied 108 were from general practitioners and of these 50% were not admitted overnight. The medical diagnoses were consistent with the lack of need for admission. Twenty three per cent of those not admitted were provided with follow up in the home within 24 hours by home care nurses whose base was the general paediatric unit; 25% were provided with open access to the ward for up to 48 hours. Only 40% of those seen and not admitted overnight were prescribed medication. We also surveyed general practitioners for their views on the appropriateness of the decision not to admit the referred patient and there was an 85% response. Of these, 70% agreed with the decision not to admit, 16% were undecided, and 9% disagreed with the decision—the main objection being parental anxiety. Interestingly, one third of all the children studied were reviewed by the general practitioner within two weeks of the acute referral. Further, the decision to discharge the child referred acutely was usually made by a senior house officer, following an assessment by an RSCN qualified nurse, and most referrals (62%) were seen out of normal working hours (Monday to Friday 09:00–17:30). Thus, many referrals do not need admission to the ward and the low re-referral rate (8%) suggests that the assessment and management were appropriate when the child was seen the first time in hospital.
We accept that the inner city community we serve may be different from that served by other paediatric units such as York, and that therefore there may be differences in the type of acute referral seen. However, we feel that the key to reducing “inappropriate” acute admissions lies elsewhere—in effective communication with our primary care colleagues complemented by experienced children’s nurses providing further assessment and advice in the home.
Drs Beverley and Ball comment:
We read with interest the comments of Doughtyet al who rightly question whether the assessment unit has caused an increase in emergency referrals. Our experience shows that the increased referral rate for admission has been part of a longer secular trend rather than as a response to the opening of the assessment unit in 1995–96 (fig 1-1).They also question whether the assessment unit had a genuine effect on patients admitted overnight but, as we say in the final paragraph of our original article, we were confident in our conclusions as three different data sets (emergency admissions requiring overnight stay, midnight occupancy, and zero length of stay) all showed that the unit allowed children to be seen and discharged home appropriately, without an overnight admission.
We were pleased to read that the team at St Mary’s Hospital were able to see and assess many children who did not require overnight hospital admission, and we agree that a separate day unit is not essential. However, we have found a separate admission area valuable for the following reasons:
• admission and discharge paperwork can be streamlined
• removal of patients who turn over very rapidly from the inpatient unit allows the care of those patients who need inpatient resources to proceed without interruption
• creation of a day ward quickly changes the culture of referral and means that when general practitioners refer patients there is not an inevitable expectation that a child will be admitted.
We also note that 50% of patients seen at St Mary’s had not been seen by their general practitioner. This compares with the nearly 75% of patients seen at York before referral to the assessment ward.
Another value of the assessment unit has been that we have been able to provide more appropriate rostering of our nursing staff and this has enabled us to have appropriately trained RSCN nurses on duty at all times.
Finally, we wholeheartedly agree that the availability of community paediatric nursing is desirable and this is a service development that we are beginning to undertake in York. It is, however, a relatively costly service whereas the introduction of the assessment unit resulted in a modest cost saving.