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Editor,—The number of admissions to hospital emergency departments is increasing, by up to five per cent a year.1 Most of these children are under 5 years of age, and they may come straight to hospital without any preceding medical examination.2 Although a short stay observation unit (SSOU) has been proved essential for a good emergency service,3 few publications have looked at its influence on the admission rate in paediatrics.4 We analysed the activity of a SSOU opened in 1992 in the paediatric emergency department (PED) of the Children's Hospital of Bordeaux. We also looked at the number of total admissions to the PED and the number of children admitted to paediatric wards between 1987 and 1996.
Among 2321 patients admitted to the SSOU in 1996, we analysed 644 medical patients (table 1): 55% of children were under 3 years old, 70% living in the town or surroundings, and only 36% referred by a general practitioner. Twenty per cent were admitted for diagnosis (group A), 50% for treatment and observation of a prediagnosed acute condition before deciding on discharge (group B), while 30% were waiting for a bed on a paediatric ward (group C). Sixty eight per cent of children spent less than six hours in SSOU, and 79% of those from groups A and B were thereafter discharged. Between 1987 and 1991, the number of medical referrals to the PED gradually increased by an average of 8.25% per year (fig 1). Similarly, admissions to paediatric wards increased by 5% per year, from 2467 in 1987 to 3541 in 1991 (fig2). Since its opening in 1992, the activity of the SSOU increased dramatically, reaching 2141 medical admissions in 1996 (fig 2), representing a mean occupancy rate of 146%. Interestingly, although the number of medical visits to the PED continued to increase during that time (fig 1), the increase in admissions to the wards was stopped, and even decreased a little from 1995 (fig 2).
Our study demonstrates the clear effectiveness of a SSOU in limiting the number of admissions to a tertiary paediatric centre. The opening of the SSOU in our hospital's PED allowed us to control the increase in inpatient admissions even though the number of medical referrals to the PED was still going up. This meant that inpatient wards were less overburdened by emergency inpatients, who generally stay a short time in hospital, but disturb work in the specialised wards. In addition, inpatients are generally assessed by medical staff twice a day only, which may result in unnecessary delays in discharge. On the contrary, continuous observation and repeated assessments of those admitted to the SSOU facilitated more rapid discharge. The shorter length of stay in this unit reduces the risk of hospital acquired infections and limits childrens' and parents' anxiety.
The SSOU in a PED can provide comprehensive, cost effective care to patients who require short term treatment or observation, especially young children. It limits inpatient admissions, improves working conditions in specialised paediatric wards, with a degree of safety that protects the PED physician and the hospital from litigation resulting from “inappropriate” discharges leading to poor outcome.