The Role of Emergency Department Observation Units

1
The Role of Emergency Department Observation Units

• Sultana Qureshi, PGY-2
• Resident Grand Rounds
• December 14, 2006

2
Principles(ACEP Guidelines)6

• The ultimate goal is to improve the quality of
  medical care to patients through extended
  evaluation and treatment while reducing
  inappropriate admissions and health care costs.
• There should be a focused goal of the period of
  observation.
• The intensity of service needs should be limited
  and consistent with the staffing pattern of the
  unit
• The patient's severity/complexity of illness
  should be limited.
• The patient should have a clinical condition that
  is appropriate for observation

3
4 models of OUs

• The scatter bed model
• The in-house defined unit model
• The linked emergency department model (current)
• Defined Unit
• Technically the ideal model, with unit attached
  to ED
• Under clinical and administrational management of
  ED

4
Evolution

• Yealy. 19891 First published on usefulness of
  OUs in EDs
• Over past 15 years, interest and implementation
  have significantly increased due to changes in
  healthcare (i.e. ED overcrowding)
• Observation Medicine official component of EM in
  U.S.
• 1997 Core Content for emergency medicine
  (AEM)2
• 2001 The model of the clinical practice of
  emergency medicine (AEM)3
• 2001 - Observation Medicine Scope of Training
  Task Force of ACEP, SAEM, RRC, EMRA, CORD, ABEM4
• 2003 A national survey of observation units in
  the United States5

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Advantages7

• Allow additional time for patients requiring
  extensive ED care before discharge
• Enlarge the emergency physician's scope of
  practice
• Unique educational experience for medical
  students and residents
• Reduce hospitalization and health care costs for
  some patients
• Allowing a more comfortable area for patient care
• More efficient flow of treatment plan

6
Advantages7

• Reduce the ED workload and improve patient flow
• 60-90 of patients can be expected to be
  discharged home after their period of
  observation8-16
• Reduce physicians' liability risks by allowing
  more time to make difficult disposition decisions
  and, thus, allow more certainty of diagnosis
  (better risk management)
• An avenue for clinical pathways
• A marketing tool and improved public relations

7
Daly et al. Short stay units and observation
medicine a systematic review. MJA 2003 178
(11) 559-563
Medical admissions Level of Evidence
Increased
No change I,4 II-112
Reduced I,7 II-16
Cost effectiveness
More costly than routine care
Cost neutral
Less costly than routine care I5
Patient quality of life
Improved I5
No change
Decreased
Patient satisfaction
Higher satisfaction I5,16
Equivalent satisfaction
Lower satisfaction
Potential benefit Level of evidence Level of evidence
Clinical outcome
Improved
No change I4,5 I4,5
Worsened
Length of stay
Increased
No change II-214 II-214
Decreased I8 I8
Efficiency of emergency department Efficiency of emergency department Efficiency of emergency department
Improved Improved II-19
No change No change
Decreased Decreased
8
Disadvantages7

• Many advantages become disadvantages if OU not
  operated properly
• Decision making may be prolonged if no clearly
  defined admission criteria, policies and
  procedures
• May become a "dumping area"
• An inadequately staffed facility will overload
  the emergency staff
• A carelessly organized and equipped unit will be
  unacceptable to the patient because of commotion
  and lack of privacy
• Lack of continuity of care secondary to sign-over

9
Clinical Indications ACEP

• Evaluation Critical Diagnostic Syndromes
• Abdominal Pain
• Chest pain (low probability of myocardial
  infarction)
• Flank pain, rule-out renal colic
• GI bleed with initial evaluation
• Chest trauma, normal initial evaluation and chest
  X-ray
• Abdominal trauma, normal initial evaluation and
  lavage
• Drug overdose, clinically stable
• Syncope, negative initial evaluation
• Vaginal bleeding, threatened abortion

• Treatment Emergency Conditions
• Allergic reactions
• Asthma
• Acute exacerbation of chronic CHF
• Dehydration
• Hyperglycemia, mild to moderate
• Hypertensive urgencies
• Selected infections (e.g., pyelonephritis)
• Seizure disorder requiring anticonvulsant loading
• Sickle cell pain crisis
• Transfusion of blood

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Table 1.   Common Diagnostic Syndromes in the Observation Unit, 1996 to 1998 Table 1.   Common Diagnostic Syndromes in the Observation Unit, 1996 to 1998 Table 1.   Common Diagnostic Syndromes in the Observation Unit, 1996 to 1998 Table 1.   Common Diagnostic Syndromes in the Observation Unit, 1996 to 1998
Chest pain 1,629 (22) 1450 (89) 8393
Asthma 1,409 (19) 1169 (83) 8384
Cellulitis 625 (8) 531 (85) 8387
Diabetic emergencies 518 (7) 466 (90) 8794
Substance abuse 425 (6) 370 (87) 8287
Pneumonia 350 (5) 266 (76) 7478
Abdominal pain 242 (3) 201 (83) 8088
Pyelonephrits 216 (3) 156 (72) 6974
Enteritis/dehydration 140 (2) 113 (81) 7784
Congestive heart failure 124 (2) 98 (79) 6283
Sickle cell crisis 123 (2) 82 (67) 5976
Seizures 84 (1) 70 (83) 7489
Other 1,622 (22) 1362 (84) 7788
Total 7,507 (100) 6334 (85) 8487

Admission to OU N ()
Discharge Home within 23 hours
Martinez et al. Am J EM. 2002110(4)
11
Chest Pain Observation Units
12

• Mid 90s numerous studies showing effectiveness
  of managing low risk cardiac chest pain in
  CPU17-23

13
A Clinical Trial of a Chest-Pain Observation Unit
for Patients with Unstable Angina (CHEER)Faroukh
et al. NEJM. 1998 3391882-1888

• Prospectively, randomized intermediate risk
  patients to CPU vs hospital-admission
• N424
• Primary outcomes
• nonfatal myocardial infarction
• death
• acute congestive heart failure
• Stroke
• out-of-hospital cardiac arrest
• Cost comparison

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15
Criticism
16
Validation of a Brief Observation Period for
Patients with Cocaine-Associated Chest PainWeber
et al. NEJM. 2003 348510-517

• Conclusion Patients with cocaine-associated
  chest pain who do not have evidence of ischemia
  or cardiovascular complications over a
  9-to-12-hour period in a chest-pain observation
  unit have a very low risk of death or myocardial
  infarction during the 30 days after discharge.

17
A comparison of emergency department versus
inhospital chest pain observation units Jagminas
et al. Am J EM. 200523(2)

• Retrospective Observational Study
• Concluded EDOU more cost effective than IHOU

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Chest Pain Unit

• Current Cochrane Review of chest pain unit
  literature.
• Berwanger, O Polanczyk, CA Rosito, GA. Chest
  pain observation units for patients with symptoms
  suggestive of acute cardiac ischaemia. Cochrane
  Database of Systematic Reviews. 4, 2006.
• Objectives
• Comparing chest pain observation units with
  routine emergency care in terms of morbidity and
  mortality
• Also comparing rates of hospital stay,
  readmission, and cost benefits

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In Summary,

• Most studied and validated clinical condition for
  OU
• So, why dont we have one
• Ideally, would need to build one adjacent to ED
• Would require extended hours for cardiology
  services (i.e. treadmill/chemical stress tests)
  to risk stratify and discharge

20
OU Management of Heart Failure
21

• Diercks et al. Am J EM. May 2006 identification
  of factors to predict OU appropriate cohort (SBPlt
  160, TnT neg)
• Peacock et al. Ann EM. Jan 2006 revised
  management protocol for HF in OU

22
Peacock et al. Observation unit management of
heart failure. Emerg Med Clin NA.200119(1)
23
Trauma Observation
24
Management of traumatically injured patients in
the emergency department observation unitWelch
R. Emerg Med Clin NA. 200119(2)
25
Management of traumatically injured patients in
the emergency department observation unitWelch
R. Emerg Med Clin NA. 200119(2)
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Is it cost-effective?

• Yes by decreasing admission rate (most studies
  assume that for every admission to the OU an
  admission is saved)
• Most studies assume that for admit to OU, an
  inpatient admission is saved
• Most above prospective studies are diagnosis
  specific
• Undetermined yet need study on physician
  impression of suitability for OU vs actual
  patient disposition

27
An evaluation of emergency physician selection of
observation unit patientsCrenshaw et al. AM J
EM. 200624(3)
28
An evaluation of emergency physician selection of
observation unit patientsCrenshaw et al. AM J
EM. 200624(3)

• Selection of patients for observation was
  suboptimal emergency physicians routinely
  identified patients as OU candidates who were not
  ultimately admitted, and they missed many
  admitted patients who might have been appropriate
  OU candidates.

29
Conclusions and areas for discussion

• Do OUs improve patient care, outcomes?
• Are OUs cost-effective?
• Should CHR plan for OU in future?
• What is more cost-effective having more ED
  acute beds vs building OU?

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Clinical Indications ACEP

• Evaluation Critical Diagnostic Syndromes
• Abdominal Pain
• Chest pain (low probability of myocardial
  infarction)
• Flank pain, rule-out renal colic
• GI bleed with initial evaluation
• Chest trauma, normal initial evaluation and chest
  X-ray
• Abdominal trauma, normal initial evaluation and
  lavage
• Drug overdose, clinically stable
• Syncope, negative initial evaluation
• Vaginal bleeding, threatened abortion

• Treatment Emergency Conditions
• Allergic reactions
• Asthma
• Acute exacerbation of chronic CHF
• Dehydration
• Hyperglycemia, mild to moderate
• Hypertensive urgencies
• Selected infections (e.g., pyelonephritis)
• Seizure disorder requiring anticonvulsant loading
• Sickle cell pain crisis
• Transfusion of blood