By : Saad Al Juma R3

Introduction Objectives Terminology Rationale Pros and Cons Mechanics Evidence conclusion

risks, benefits, and requirements to develop an ED observation unit or clinical decision unit

Recognize what is required to develop and manage these units and programs

Recognize the conditions that can be better managed through these programs

ED Observation Unit (EDOBS) Clinical Decision Unit (CDU) Rapid Diagnostic Unit (RDU)

dedicated area within or directly adjacent to the ED

defined nursing and physician staffing. clearly defined written policies and

procedures for management of certain medical problems within specific time limits. It must be provided with equipment and supplies appropriate for the kinds of patients treated.

dedicated area within or directly adjacent to the ED

defined nursing and physician staffing. clearly defined written policies and

procedures for management of certainmedical problems within specific time limits. It must be provided with equipment and supplies appropriate for the kinds of patients treated.

dedicated area within or directly adjacent to the ED

defined nursing and physician staffing. clearly defined written policies and

procedures for management of certainmedical problems within specific time limits. It must be provided with equipment and supplies appropriate for the kinds of patients treated.

Clearly defined admission criteria Well planned policies and procedures Clear chain of command Proper staffing, location, and equipment Carefully developed programs for quality

assurance and utilization review.

What is the current context of Emergency Medicine?

Crowding / Increasing volume

Saturated inpatient bed capacity/ Decreasing access inpatient beds

EMS diversion

Problem with missed MIs, TIAs that return as a stroke, or door-to balloon times.

Increasing Length of Stay (LOS)

No

No

Services are an extension of ED evaluation and stabilization services beyond the traditional two-to three-hour limit

Benefit better definition of the patient's problem with

reduction in both costs and inappropriate dispositions.

Ultimate goal improve the quality of medical

reducing inappropriate admissions and health care costs.

PROS : Allow additional time , extensive ED care before

discharge

Enlarge the emergency physician's scope of practice providing a longer period of time to observe the effects of ED treatments and changes in the patient's clinical condition;

Add an educational experience for medical students and residents that is not available in the traditional outpatient setting;

PROS : (Cont’) Reduce hospitalization and health care costs for some

patients , while allowing a more comfortable area for patient care;

Reduce the ED workload and improve patient flow;

Reduce physicians' liability risks by allowing more time to make difficult disposition decisions and, thus, allow more certainty of diagnosis. While the patient is still in an observation setting, outpatient management strategies can be initiated and examined to ensure appropriateness.

CONS:

Lack of clearly defined admission criteria, policies and procedures, and direct lines of command may prolong decision making and disposition

Dumping Area

An inadequately staffed facility will overload the emergency staff

CONS : (cont’)

Carelessly organized and equipped unit will be unacceptable to the patient because of commotion and lack of privacy

Patient care may suffer from the lack of continuity of care as emergency physicians change from one shift to the next if signout procedures are not followed.

Lack of control/agreement over extent of work up

sensitivity vs. specificity in the ED/ The Drive for Specificity

Stop Counting Visits and start counting “BED HOURS” We must get paid for what we do Time increases diagnostic accuracy EP can no longer be forced into ‘home vs

admit’ dichotomy

EDOBS/Rationale Why is this maxim true? Because we know that certain patients will

benefit From

FURTHER TESTING

F URTHER TREATMENT

More time will allow us to apply more specificity to the decision yielding a benefit to the patient, the institution and the professional staff

What are the important design features? The unit should be contiguous to the Emergency

Department▪ resuscitate any person who is admitted to the unit.

▪ cardiac monitoring

▪ IVAC capabilities

▪ inhalation therapy equipment, depending upon the unit.

curtain vs. cubicles vs. Rooms

real hospital beds

some provision for food

TV

The number of beds range from four to 20 beds on the unit

equal to 10% to 40% of the ED bed capacity

Both Physicians and Nurses need to have broad-based knowledge and experience in the management of a wide variety of disease processes

The average staff is one registered nurse per four to six patients in monitored beds and one registered nurse per six to nine patients in non-monitored beds

Calculations of the physician staffing for the amount of additional services will be approximately one full-time equivalent for every 2000 patients observed per year

ancillary personnel:

depend on the size and type of services

Adequate secretarial and clerical staff

Basic Rules

Have to be able to walk

Stable condition

80% chance of going home

Safety reasons

Social/Financial reasons

Pt. Satisfaction reasons

Role of age

a focused goal of the period of observation.

Low probability but high mortality

▪ Chest pain

▪ RIF pain

short-term therapy for an emergency conditions

▪ asthma

▪ dehydration

The intensity of service needs should be limited and consistent with the staffing pattern of the unit

the patient's severity of illness should be limited

one organ system

must not preclude the expectation that the patient will be discharged within established time limits

The patient should have a clinical condition that is appropriate for observation

Diagnostic Evaluation Short Term Therapy Psychosocial Needs

Abdominal Pain Allergic reactions Alcohol intoxication

Vaginal bleeding, threatened abortion

Asthma Adjustment reaction

Chest pain (low probability of myocardial infarction)

Acute exacerbation of chronic CHF Depression

Syncope, negative initial evaluation Dehydration Psychosis

Flank pain, rule-out renal colic Hyperglycemia, mild to moderate Social disposition problems

GI bleed with initial evaluation Hypertensive urgencies

Chest trauma, normal initial evaluation and chest X-ray

Selected infections (e.g., pyelonephritis)

Abdominal trauma, normal initial evaluation and lavage

Seizure disorder requiring anticonvulsant loading

Drug overdose, clinically stable Sickle cell pain crisis

Transfusion of blood

Physician can not identify a goal of patient care that can reasonably be expected to be met within a time limit

unstable vital signs

myocardial infarction

comatose condition

Discrete end-point yields success When observation beds are permitted Written policies and procedures address the

type of patient use

the maximum time period of use

the mechanism for providing appropriate surveillance

the type of nurse/patient system to be used

A time limit is most important and should be carefully monitored and strictly enforced.

Many ED observation unit have time limits of 12 or 24 hours.

An admission note

the reason for the period of observation

working diagnosis

treatment plan

clearly defining the end point for patient disposition is mandatory.

The ED personnel (physician, nurse, PA, etc.) should examine the patient and write regular progress notes.

“OBS resets the attention clock” And Reduces exposure to hazard by short LOS

Good studies for

Asthma

Chest Pain

Unstable Angina

A Fib

Same conclusion

Faster, Better, Cheaper

Marx: Rosen's Emergency Medicine, 7th ed.

CHAPTER 196 – Observation Medicine and Clinical Decision Units

American College of Emergency Physicians, www.acep.org

National Library of Medicine–National Institutes of Health, www.nlm.nih.gov