More children being admitted to hospital in the UK - why and what can be done?

According to a study recently published in Archives of Disease in Childhood it appears that more children are being admitted to  hospital (Gill et al 2008 Arch Dis Child 98 328-334).  While the figures are a bit rough and ready, the trends presented are fairly clear and include:

1. A fairly continuous increase in the number of admissions since 2003; in the preceding 4 years (1999-2003) it was fairly static.
2. Overall the increase in admissions since 1999 is 28%: in those under 1 year of age it is 33% which is the highest, the lowest was in the 10-14 year age group which was only (!) 13%.
3. This increase is not because children are getting much sicker, as mortality fell over the same period.
4. Much of the increase is the result of infectious diseases and other conditions such as asthma that could be managed in the community.
5. Admissions for chronic conditions fell a little.
6. Most of the increase was for very short stays, the largest increase being among children admitted for less than one day.

This presents a challenge, because this is clearly not sustainable, and is not good for the children concerned.  It is now over 50 years since the Platt Report which said, should only be admitted to hospital when "the medical treatment they require cannot be given in other ways without disadvantage."  Ironically, the report goes on to say "This may seem obvious but ...... evidence submitted to us suggests that it is still often overlooked."

What is even more perplexing is that over this same period there has been a strong emphasis upon caring for children in the community; provision of alternative methods of getting health care advice such as NHS Direct, the introduction of Children's Centres, and the publication of guidelines such as the NICE Fever Guidelines.

The authors give a long list of possible reasons for this increase.  These seem to fall into 3 categories:

• Social - parents are less able or willing to look after children at home; or their threshold for seeking hospital advice is lower.
• Clinical - more children are being sent to hospital by NHS Direct/GPs; hospitals are not as good at triaging as they were; or practice is becoming more defensive, leading to more children being admitted to be on the safe side
• Organisational - admitting children to avoid breaching A&E targets by observing for longer; changes in contracts and financial incentives that reward admission.

Positives are that the increase in shorter stays may be party due to the fact that we discharge quicker.  That is about it for the positives!

Whatever the reason, this is not good and we must find a way of changing this trend.  One example of innovative thinking is the Traffic Light contained within the NICE Fever Guidelines which splits symptoms into categories (red, amber, green) which is designed to help divide symptoms into those indicative of high; low and intermediate risk of serious illness.  More is needed.  This may be an area where pharmaceutical companies can help, using their marketing expertise to produce quality parent friendly information.

Challenging the paediatric ward discharge status-quo

One of the unwritten rules of paediatric medicine is that once a child is admitted to a ward they will stay over-night; and if they are ok they will bed and breakfast and probably go home the next morning.  That is one of the reasons that assessment and observation units were set up.  A recent paper in JAMA Pediatrics by Stephanie Iantorno and Evan Fieldston challenges this assumption, and in particular the idea that morning discharges are necessarily a measure of good practice.  One quote in particular seemed pertinent..."accommodating evening discharges can enhance the patient centeredness of care; families have obligations and barriers, including employment and transportation, that make morning discharges difficult and undesirable."

This seems to be one of the biggest challenges for health systems around the world - not just providing high quality care; but also care that fits in with today's lifestyles and expectations that things should happen when we want them to happen or when we need them to happen.  This is an American paper, and of course the health system there is very different to the UK; but the same challenges exist.  Some of this can be seen in the case of general practice hours - which often don't fit in with the hours of those who work in the day.  Another surprisingly important issue in London is avoiding the rush-hour; 07.00-10.00 and 16.00-19.00 are not good discharge times, particularly if one is relying on public transport!