Was the Pediatric Emergency Was the Pediatric Emergency Department or Pediatric Department or Pediatric

Urgent Care Center Setting Urgent Care Center Setting More Affected by the Fall, More Affected by the Fall,

2009 H1N1 Influenza 2009 H1N1 Influenza Outbreak?Outbreak?G. Conners, MD, MPH, MBA; T. G. Conners, MD, MPH, MBA; T.

Hartman, MHA; M. Fowler, MD; Hartman, MHA; M. Fowler, MD; L. Schroeder, MD; T. Tryon, MDL. Schroeder, MD; T. Tryon, MDChildren’s Mercy Hospitals & Children’s Mercy Hospitals &

Clinics, Kansas City, MOClinics, Kansas City, MO

Background The H1N1 influenza outbreak of Fall, The H1N1 influenza outbreak of Fall,

2009 stressed the resources of our 2009 stressed the resources of our pediatric emergency department pediatric emergency department (PED) and two pediatric urgent care (PED) and two pediatric urgent care centers (PUCCs).centers (PUCCs).

As the leaders of the Division that As the leaders of the Division that manages both areas, we had to manages both areas, we had to make PED versus PUCC resource make PED versus PUCC resource allocation decisions based on allocation decisions based on guesswork, rather than data. guesswork, rather than data.

Background We sought to learn from our We sought to learn from our

experience, in order to determine experience, in order to determine whether the PED or the PUCC whether the PED or the PUCC setting had been more affected, to setting had been more affected, to help guide future decision-making.help guide future decision-making.

Our areas of focus for this analysis: Our areas of focus for this analysis: overall volumes (# patients overall volumes (# patients

registering)registering) rates of elopement (either left before rates of elopement (either left before

seen or during evaluation)seen or during evaluation)

Setting Free-standing, academic children’s Free-standing, academic children’s

hospital in Kansas City, MO:hospital in Kansas City, MO: Main hospital:Main hospital: ~70,000 annual visit

PED Northland:Northland: multiple pediatric sub-

specialty clinics in North K.C., including a noon-10 PM PUCC (~23,000 / yr)

South:South: multiple pediatric sub-specialty clinics / inpatient beds in Overland Park, KS, including a 24/7/365 PUCC (~55,000 / yr)

Methods Fall, 2009 H1N1 influenza outbreak period: Fall, 2009 H1N1 influenza outbreak period:

8/1/09 – 11/15/098/1/09 – 11/15/09 Using an administrative database, we Using an administrative database, we

compared patient data during this period with compared patient data during this period with those of the same dates in 2008those of the same dates in 2008: Patients who registeredPatients who registered** (volume) (volume) Rates of patients who eloped (either left Rates of patients who eloped (either left

before seen or during evaluation)before seen or during evaluation) We combined data from the two PUCC sitesWe combined data from the two PUCC sites

*We adjusted (increased) the Fall, 2008 Northland PUCC volume *We adjusted (increased) the Fall, 2008 Northland PUCC volume by 8.6%, to account for increased service hours in Fall, 2009 by 8.6%, to account for increased service hours in Fall, 2009 versus Fall, 2008 (adjustment determined by comparing versus Fall, 2008 (adjustment determined by comparing 12/09-3/10 with 12/08-3/09)12/09-3/10 with 12/08-3/09)

Methods We statistically compared overall We statistically compared overall

patient volumes using chi-square patient volumes using chi-square test, and changes in elopement test, and changes in elopement rates using Poisson regression. rates using Poisson regression.

Our IRB deemed this a quality Our IRB deemed this a quality improvement project, not subject to improvement project, not subject to IRB approval.IRB approval.

Results: Volume

# patients# patients

20082008 2009 2009 (H1N1)(H1N1)

IncreaseIncrease

PEDPED 18,575 21,805 3230 (17.4%)

PUCCPUCC 19,431* 24,488 5057 (26.0%)

PUCC increase > PED increase p<.0001PUCC increase > PED increase p<.0001

Results: Elopement Rates

# patients# patients

20082008 2009 2009 (H1N1)(H1N1)

Absolute Absolute IncreaseIncrease(rate (rate increase)increase)

PEDPED 698 (3.8%)

1296 (5.9%)

598 (58%)

PUCCPUCC 227 (1.2%)*

779 (3.2%)

552 (172%)

PUCC rate increase > PED rate increase p<.0001PUCC rate increase > PED rate increase p<.0001

Results Both the PED and PUCC Both the PED and PUCC

settings experienced settings experienced substantial surges in patient substantial surges in patient volume and elopement rates volume and elopement rates during the Fall, 2009 H1N1 during the Fall, 2009 H1N1 influenza outbreak.influenza outbreak.

Results: Volume The PUCC setting had both a The PUCC setting had both a

larger absolute increase (5057 larger absolute increase (5057 versus 3230) and relative versus 3230) and relative increase (26.0% versus 17.4%) increase (26.0% versus 17.4%) in patient volume than did the in patient volume than did the PED during the Fall, 2009 H1N1 PED during the Fall, 2009 H1N1 influenza outbreak.influenza outbreak.

Results: Elopement Rates

The PUCC setting had a larger The PUCC setting had a larger elopement rate increase (172% elopement rate increase (172% for PUCC versus 58% for PED) for PUCC versus 58% for PED) and nearly as large an absolute and nearly as large an absolute elopement increase (552 for elopement increase (552 for PUCC versus 598 for PED) than PUCC versus 598 for PED) than did the PED during the Fall, did the PED during the Fall, 2009 H1N1 influenza outbreak.2009 H1N1 influenza outbreak.

Discussion Q: Was the PED or the PUCC Q: Was the PED or the PUCC

setting more affected by the setting more affected by the Fall, 2009 H1N1 influenza Fall, 2009 H1N1 influenza outbreak?outbreak?

A: The PUCC!A: The PUCC!

Discussion This suggests that, when This suggests that, when

allocating resources between allocating resources between the PED and the PUCC during a the PED and the PUCC during a large-scale influenza (or similar) large-scale influenza (or similar) outbreak, the PUCC should outbreak, the PUCC should receive a substantial, and receive a substantial, and perhaps a majority, share.perhaps a majority, share.

Two Major Limitations1.1. We have measured and compared We have measured and compared

the the quantityquantity, not the , not the qualityquality, of the , of the effects of the Fall, 2009 H1N1 effects of the Fall, 2009 H1N1 outbreak on PED and the PUCC. outbreak on PED and the PUCC.

Related issues: Related issues: who came to each setting for carewho came to each setting for care acuity differencesacuity differences who eloped, and why? , etc.who eloped, and why? , etc.

Two Major Limitations2.2. Inherent limitations of our Inherent limitations of our

research design: before-after research design: before-after study using an administrative study using an administrative database.database.

Related issues: Related issues: changes in other factors between changes in other factors between

2008 / 2009? 2008 / 2009? accuracy of administrative data?accuracy of administrative data? the baseline adjustment we made, the baseline adjustment we made,

etc.etc.

Conclusions Both the PED and PUCC were very affected Both the PED and PUCC were very affected

by the Fall, 2009 H1N1 influenza outbreak.by the Fall, 2009 H1N1 influenza outbreak.

In terms of volume of patients seen and In terms of volume of patients seen and increase in elopement rates, the increase in elopement rates, the PUCC PUCC setting was more affected than the PED setting was more affected than the PED settingsetting..

Although not the whole story, given the Although not the whole story, given the limitations, this information will be useful limitations, this information will be useful when allocating resources in future, similar when allocating resources in future, similar situations.situations.

Thank you!

Thank you!

Questions?Questions?