Implementation and Evaluation of Pediatric Observation Protocols in the Emergency Department – Funded by the Center for Healthcare Research and Transformation (CHRT)

Faculty Contact: Michelle L. Macy, MD, MS

After initial treatment, many emergency department (ED) patients require a period of observation to ensure that treatment is effective and no additional problems arise. ED physicians must determine whether that observation period, typically <24 hours, should occur in the ED or the inpatient ward. However, this decision is complicated by the forces of ED crowding and inpatient capacity. When the ED waiting room is full, there is a push for rapid admission, which may result in overutilization of inpatient services. When hospital beds are full, extended ED care may replace an inpatient stay. The development of an effective mechanism for ED-based observation would be of clinical benefit, with potential cost-savings.


  1. Describe clinical outcomes among patients who are treated according to an observation protocol and those eligible for observation.
  2. Evaluate ED and inpatient length of stay and cost parameters, comparing patients who are treated on an observation protocol versus those eligible for observation.
  3. Examine the impact of observation protocols on ED patient flow and inpatient capacity.
  4. Evaluate acceptability of observation protocols and barriers to protocol utilization.

In April 2009, the UM Pediatric ED began using observation protocols to provide extended ED treatment ("observation care") to children with the following conditions: asthma, bronchiolitis, pneumonia, croup, dehydration, migraine headache, closed head injury, ingestion, diabetic ketoacidosis, cellulitis and abscess.

Objectives 1 and 2: For the 12 months following protocol implementation, we will track clinical outcomes (including tests and treatments), ED and inpatient lengths of stay, final disposition, for all pediatric patients with ICD-9 code discharge diagnoses that would be potentially eligible for protocol-based observation care. We will also track return visits to the ED or inpatient services in the 30 days following discharge from observation. We will perform a cost analysis of observation protocol versus inpatient care for comparable disease states and lengths of stay.

Objective 3: The impact of observation protocols on ED patient flow and ED crowding will be determined utilizing the NEDOCS crowding metrics. C.S. Mott Children's Hospital capacity will be assessed by measuring the percentage of filled beds for the general care and Pediatric ICU services.

Objective 4: We will conduct key informant interviews with ED physicians and nurses to determine the acceptability and barriers to use of observation protocols.

For more information, please contact:
Michelle L. Macy, MD, MS
Clinical Lecturer
Departments of Emergency Medicine and Pediatrics
Child Health Evaluation and Research Unit
University of Michigan
300 North Ingalls Building Room 6C13
Ann Arbor, Michigan