Costs of sedation using oral midazolam: money, time, and parental attitudes

OBJECTIVE: Many agents suitable for pediatric outpatient sedation have been identified and compared, but less data have appeared on the effect of sedation use on Emergency Department (ED) length of stay (LOS) or visit costs. We sought to discover the relationship between one commonly used method of sedation, orally administered midazolam, and ED LOS and visit costs. Parents were then surveyed to determine their attitudes toward sedation given knowledge of these costs. METHODS: All ED patients under 10 years of age seen in a pediatric ED during April and May of 1996 for repair of lacerations <2.5 cm in length were identified via retrospective chart review. Children were excluded if they had other significant injuries, received sedatives other than oral midazolam, or were repaired by non-ED physicians. Preliminary cost and LOS data from this review was used to create a parental survey measuring attitudes toward the costs of an unnamed form of sedation (not mentioning oral midazolam). A convenience sample of parents in an ED waiting room were asked if they would want sedation administered to a child needing sutures if this increased the visit cost by $100 and/or increased LOS by 30 minutes. Parents were then asked to re-answer these questions assuming that the sedation medication was effective only 50% of the time. RESULTS: Of 120 patients meeting entry criteria, 57 (48%) received oral midazolam. Children sedated with this agent were significantly younger (3.6 vs. 4.6 years, P = 0.015), had more layered repairs (30% vs. 14%, P = 0.047), and more facial lacerations (84% vs. 63%, P = 0.01) when compared with nonsedated patients. Mean LOS for patients with simple lacerations receiving oral midazolam increased by 17.1 minutes (P = 0.03) compared with nonsedated children; for layered repairs, the mean increase was 30.9 minutes (P<0.05). The use of oral midazolam did not effect physician charges, but did significantly increase mean combined nurse/hospital charges and total charges by 73 to 87 dollars, depending on laceration type (P<0.001 all cases). Of 81 parents surveyed, 81% said that they would be willing to wait 30 extra minutes for sedation to be used; this figure fell to 73% if sedation was effective 50% of the time. Seventy-five percent of parents were willing to pay $100 extra for sedation; 67% if sedation was effective only half the time. Willingness to endure a longer LOS or pay increased charges was not associated with parental sex or insurance status. CONCLUSION: The use of oral midazolam significantly increases ED visit LOS and cost. This information is important to review with parents when discussing sedation options. Up to one third of parents surveyed would not want to wait extra time or pay extra money for sedation to be administered, especially if the efficacy of the chosen method was not assured.